_^o_ 



Wtggm 



m 



y ;r.ir^ 



HHran 






•as* 









H^^^IV 



IH 



MmmKHft 

HK^KHtiHHjEZei 



pPPPSH 

mhmmD 



H Bilnl 







Hi 

Hub 
Rifts 

sun 

HBHH 
MBMiBficeaifln 

Dgsranra 
BH 

H - Hmi 
■H HSES! Bffi 



BH 

■H nffl 

HzsSBKSi 

B9H 




TREATISE ON FRACTURES. 



BY 



J. F. MALGAIGNE, 



CHIRURGHN DE L'HOPITAL SAINT-LOUIS, CHEVALIER DE LA LEGION D'HONNEUR ET DU m£rITE 
MILITALRE DE POLOGNE, MEMBRE DE L'ACADliMLE ROYALE DE MEDECINE. 



WITH ONE HUNDRED AND SIX ILLUSTRATIONS. 



TRANSLATED FROM THE FRENCH, 



Mxt\ DfaUs ani. JHrJriti0n« t 



JOHN H. PACKARD, M.D. 




PHILADELPHIA: 

J. B. LIPPINCOTT & CO. 

1859. 






Entered, according to Act of Congress, in the year 1858, by 

JOHN H. PACKAKD, M.D., 

In the Clerk's Office of the District Court of the United States for the Eastern 
District of Pennsylvania. 






TRANSLATOR'S PREFACE. 



In presenting to the profession an American translation 
of M. Malgaigne's Treatise on Fractures, I beg to call at- 
tention to a few points connected with my own share in the 
work. The importance of the subject needs no comment 
to those who have had any practical experience in surgery; 
nor is it necessary to adduce any other proof of M. Mal- 
gaigne's position as a standard authority than the extent to 
which he is quoted by other surgical writers. 

I have made it my great aim to render the text of the 
author as faithfully as possible, endeavoring at the same 
time to avoid offending the taste of the reader by the use 
of Gallic idioms. The notes which I have taken the liberty 
to insert are intended to set forth peculiarities in American 
views and practice, or accounts of cases in point; in one or 
two instances I have been able to look up quotations which 
were beyond my author's, reach. An index has also been 
added, and a list, as full as circumstances would allow, of 
works hitherto published upon the same subject. 

As a matter of course mention is frequently made, 
throughout the volume, of weights and measures. Where 
these occur, I have in some cases substituted English values, 
sometimes annexed English equivalents to the French ex- 
pressions, and sometimes allowed the latter to stand by 
themselves. For the convenience of the reader, a table 

(7) 



8 TRANSLATOR S PREFACE. . 

will be added containing the French and English standards, 
and showing their relative proportions. 

Most of M. Malgaigne's illustrations are comprised in a 
folio atlas of lithographic plates; these have been reduced 
one-half, and engraved on wood. For greater facility of 
reference, they have been collected at the end of the 
volume, instead of being interspersed throughout the text. 

There are some French words which have a very differ- 
ent signification from that of their analogues in English; 
thus simple means with us, in regard to fractures, excluded 
from the air ; while in French it corresponds to our word 
single. These differences have been explained in notes, 
wherever any confusion seemed likely to arise. 

In conclusion, I must express my thanks to Dr. Norris, 
for his kind assistance in my search after several important 
references ; to Dr. Henry D. Noyes of New York, and Dr. 
Christopher Johnston of Baltimore, for accounts of cases, 
and valuable information as to some practical points; and 
to Dr. F. H. Hamilton of Buffalo, for various original pam- 
phlets bearing on the subject in hand. 

1225 Spruce Street,") 
Philadelphia, 1858.) 



P K E F A C E. 



I now offer to the public the first part of a work long since con- 
ceived of, with a view of filling a gap in our surgical literature. 
England and Germany have already produced several treatises upon 
fractures and luxations; and it is perhaps surprising that France 
should be behind-hand. 

It is however necessary, in a matter so important, that we should 
be in possession of something more than is contained in our general 
treatises on pathology. We are beyond the time when Richerand 
declared that the treatment of luxations, for instance, was almost 
in that ideal state called perfection. Numerous recent works have 
shown how many errors and omissions exist in the history of this 
class of injuries, so that this fact does not need to be insisted upon 
here. In regard to fractures, the demonstration is not so clear; yet 
I am ready to assert that their study is not in a more advanced state 
than that of luxations, and that too often, in both, imaginary lesions 
are pointed out, and real ones unrecognised. 

The character which I have mainly sought to give this work is 
that of reality. In a historical point of view, I have aimed at pre- 
senting a resume of all the doctrines and ideas maintained from the 
earliest times to our own day, having recourse as much as possible 
to the original works. As to my teachings, I have asserted nothing 
unsupported by facts, drawn either from my own experience or from 
that of others. Where clinical observation was insufficient, I have 

1* (9) 



10 PREFACE. 

sought a substitute for it in experiments upon dead bodies, or upon 
the lower animals; but above all, I have tried to clear up a great 
many mooted points by throwing upon them the light of pathological 
anatomy; and this is the object of my atlas. 

In order to enrich this atlas as much as possible, I have not hesi- 
tated to levy contributions in all quarters. Besides my own collec- 
tion, I have drawn upon the three great museums of Paris ; for the 
liberality with which these treasuries of science have been thrown 
open to me, I owe my thanks to the Conseil des Hopitaux, and to 
M. Serres, director of the Musee des Hopitaux; to the secretary of 
the Faculte de Medecine for the Musee Dwpuytren ; to M. Gama, 
for the museum at Val-de-Grace. And since fortune is capricious, 
whenever I came upon a rare and important specimen in any cabinet, 
I hastened to secure it for the benefit of my atlas ; in this way get- 
ting hold of perhaps more material than any other author has ever 
had. 



TABLE OF CONTENTS, 



CHAPTER I. 

PAGE 

Of Fractures in General 17 

Article I. — Etiology 17 

I I. — General Predispositions 17 

II. — Of some Affections predisposing to Fracture 25 

III. — Of the Determining Causes of Fracture , 34 

Article II. — Varieties of Fractures , 42 

\ I. — Of Incomplete Fractures 42 

(1) Of Fissures 42 

(2) Of Incomplete Fractures, properly so called 48 

(3) Of Splintered Fractures 56 

(4) Of Perforations 58 

II.— Of Complete, Simple Fractures 63 

(1) Of Transverse Fractures 63 

(2) Of Serrated Fractures 64 

(3) Of Oblique Fractures.. 67 

(4) Separation of the Epiphyses 69 

HI.— Of Multiple Fractures* 73 

(1) Of Fractures with Splinters 73 

(2) Of Fractures with several Fragments 74 

(3) Of Fractures by Crushing 75 

(4) Of Fractures involving several bones at once 76 

IV. — Of Complicated Fractures 78 

Article III. — General Semeiology 80 

Article IV. — Course and Terminations 96 

\ I.— Of the Exterior Phenomena 96 

II.— Of the Formation of the Callus 102 

III.— Of the Transformations of the Callus 107 

IV. — Theory of Anchylosis following Fracture 116 

V. — Of Non-union, or False Joint after Fracture 120 

* [By some mistake the heading of this section has been made to read "Com- 
minuted," in the body of the work. I trust the evident incorrectness of that title 
will prevent any one from being misled by it.] 

(ii) 



12 TABLE OF CONTENTS. 

PAGE 

Abtiolr V. — Diagnosis 137 

Ai:i [( ILB VI. — Prognosis 140 

Ai: i [OLE VII. — Treatment 142 

g I.— Of the First Attentions to the Patient 143 

II. — Of the proper position for the Limb 147 

III.— Of the Reduction 156 

iV. — Of the proper Time for Attempting Reduction 163 

V.— Of Apparatus 167 

(1) Ordinary Apparatus or Splints 167 

(2) Immovable Apparatus 177 

(3) Of the Plaster Apparatus 182 

(4) Of Cuirasses 186 

(5) Of Hyponarthecic Apparatus 187 

(6) Of Apparatuses for Permanent Extension 196 

VI. — Of the Choice of Apparatus 201 

VII. — Of the proper Time for applying the Apparatus 204 

VIII. — Of the Time for removing the Apparatus .- 208 

IX. — Of the Movements which may be allowed to the Patient 210 

X. — Of the Treatment of Complicated [Compound] Fractures 216 

XL— Of the Treatment of Symptoms 226 

XII. — Of Convalescence from Fractures 237 

XIII. — Of Hindrances to Consolidation 241 

XIV. — Of Operations for the Cure of Pseudarthrosis 246 

XV. — Of Secondary or Recurring Fractures 261 

XVI.— Of Deformed Callus, and its Treatment 265 

XVII. — Of Some Diseases of the Callus 278 

XVIII. — Of Cases Requiring Amputation 283 



CHAPTER II. 

Of Fractures of tite Upper Jaw 288 

\ I. — Fractures of the Zygomatic Arch 289 

II. — Fractures of the Malar Bone 291 

III.— Fractures of the Nose 293 

IV. — Fractures of the Upper Maxillary Bones 299 

CHAPTER III. 

Of Fractures of the Lower Jaw.. 305 

I I.— Fractures of the Body of the Bone 305 

II. — Fractures of the Neck of the Jaw-Bone 322 

CHAPTER IV. 

Of Fractures of the Hyoid Bone, etc 326 

£ I.— Fractures of the Hyoid Bone 326 

II. — Fractures of the Laryngeal Cartilages .* 329 



TABLE OF CONTENTS. 13 

CHAPTER V. page 

Of Fractures or the Vertebra 331 

| I. — Fractures of the Spinous Processes 331 

II. — Fractures of the Vertebral Arches 333 

III. — Fractures of the Bodies of the Vertebrae 337 

CHAPTER VI. 
Or Fractures of the Ribs 346 

CHAPTER VII. 
Of Fractures of the Sterno-Costal Cartilages 359 

CHAPTER VIII. 
Of Fractures of the Sternum 363 

CHAPTER IX. 

Of Fractures of the Clavicle 374 

\ L— Fractures of the Body of the Clavicle.., 375 

II. — Fractures of the Sternal Extremity 396 

III. — Fractures of the Acromial Extremity 397 

IV.— Fractures of both Clavicles 398 

CHAPTER X. 

Of Fractures of the Scapula 402 

I I.— Fractures of the Body of the Scapula 402 

II. — Fractures of the Acromion 407 

III. — Fractures of the Coracoid Process 412 

CHAPTER XL 

Of Fractures of the Humerus 414 

\ I. — Extra-Capsular Fractures, or those of the Cervix Humeri 415 

II. — Intra-Capsular Fractures, or those of the Head of the Bone 424 

III.— Fractures of the Shaft of the Humerus 429 

IV. — Fractures of the Humerus above the Condyles 437 

V. — Fractures of the Epitrochlea [internal condyle] 441 

CHAPTER XII. 

Of Fractures of the Elbow 445 

\ I. — Fractures of both Condyles of the Humerus 445 

II. — Fractures of the External Condyle 448 

III. — Fractures of the Trochlea, or Internal Condyle 451 

IV. — Fractures of the Olecranon 453 

V. — Comminuted Fractures of the Elbow 468 



14 TABLE OF CONTENTS. 



CHAPTER XIII. page 

Of Fractures of the Bones of the Forearm 470 

g I. — Fractures of the Forearm 471 

II.— Fractures of the Ulna 480 

III.— Fractures of the Shaft of the Radius 482 

IV. — Fractures of the Lower Extremity of the Radius 485 



CHAPTER XIV. 

Of Fractures of the Bones of the Hand 499 

g I. — Fractures of the Carpal Bones 499 

II. — Fractures of the Metacarpal Bones 500 

III. — Fractures of the Phalanges 507 



CHAPTER XV. 

Of Fractures of the Pelvis 511 

§ I. — Fractures of the Sacrum 512 

II. — Fractures of the Coccyx : 516 

III.— Fractures of the Crista Ilii ; 516 

IV.— Fractures of the Os Pubis 519 

V. — Fractures of the Ischium 521 

VI.— Double Vertical Fractures of the Pelvis 523 

VII. — Fractures in the Cotyloid Cavity 527 



CHAPTER XVI. 

Of Fractures of the Femur 529 

§ I. — Intra-Capsular Fractures of the Cervix Femoris 530 

II. — Extra-Capsular Fractures of the Cervix Femoris 551 

III. — Fractures of the Great Trochanter 570 

IV. — Fractures just below the Trochanters 572 

V.— Fractures in the Middle Third of the Femur 578 

VI. — Fractures of the Femur just above the Condyles 588 

VII. — Fractures of one Condyle of the Femur 592 

VIII. — Fractures of both Condyles at once 595 

IX. — Compound Fractures of the Femur , 596 



CHAPTER XVII. 

Of Fractures of the Patella 599 

\ I.— Transverse Fractures of the Patella 599 

II.— Vertical Fractures of the Patella 626 

III.— Multiple Fractures of the Patella 628 



TABLE OF CONTENTS. 15 

CHAPTER XVIII. page 

Of Fractures of the Bones of the Leg 630 

I I. — Fractures of the Leg 630 

II. —Fractures of the Tibia 645 

III.— Fractures of the Fibula 648 

IV. — Fractures just above the Malleoli 659 

V.— Fractures of the Malleoli , 662 



CHAPTER XIX. 

Of Fractures of the Foot 665 

\ I. — Fractures of the Astragalus 665 

II. — Fractures of the Calcaneum 666 

III. — Fractures of the Metatarsal Bones 673 

IV.— Fractures of the Phalanges of the Toes 674 



Bibliographical Table 677 



TABLE 

SHOWING THE RELATIVE VALUES OF FRENCH AND ENGLISH STAND- 
ARD WEIGHTS AND MEASURES. 

(From Hoblyrfs Medical Dictionary.) 



Millimetre 


= 


•0393T inches. 




Centimetre 


= 


•393T1 " 




Decimetre 


= 


3-93U0 " 




Metre 


= 


39-3T100 " 


4 


Decametre 


= 


393-U000 " = 


10 yds., 2 ft, Win. 


Litre 


= 


21133 pints. 




Milligramme 


= 


•0154 grains. 




Centigramme 


= 


•1544 " 




Decigramme 


= 


1-5444 " 




Gramme 


= 


15-4440 " 




Decagramme 


= 


154-4402 " = 


(2 dr., 34-3 gr. Troy, or 
(5-65 dr. Avoirdupois. 


Hecate-gramme = 

"K'ilnn'rnmmp = 


1544-4023 " 


9 lh R r>7 5rlr Avnirdrm 



The millimetre may for general purposes be estimated with sufficient 
accuracy as = ^ of an inch ; the centimetre as = | of an inch ; the 
metre as somewhat over a yard; the gramme as = about 15 grs. Troy; 
the kilogramme as something over 2 lbs. Avoirdupois. The ligne and 
the pouce correspond respectively to j 1 ^ of an inch and one inch ; and 
the livre to about 1 lb. Avoirdupois. Wherever greater exactitude has 
seemed desirable, as was stated in the preface, the English equivalents 
have been merely annexed to the French expressions, or the latter have 
Ween allowed to stand by themselves. 

(16) 



A TREATISE ON FRACTURES. 



CHAPTER I. 

OF FRACTURES IN GENERAL. 

The word fracture, (fractura, from frango, I break,) or, in com- 
mon language, breaking, conveys to the mind so clear an idea that a 
definition might, perhaps, tend only to obscure it. If, however, one 
must be adopted, I should say that fracture is the division, by vio- 
lence, of bones or of cartilages. 

The study of fractures in general is of such importance, that one 
may say that without it the history of each particular fracture would 
necessarily remain obscure and incomplete. In order to omit none 
of the questions it involves, we shall arrange it under seven heads, 
treating successively (1) of the etiology, (2) of the varieties, (3) of 
the symptoms, and (4) of the course and terminations of fractures — 
subjects belonging almost exclusively to pure science. Then passing 
to the application, which properly constitutes art, we shall take up 
(5) the diagnosis, (6) the prognosis, and (7) the treatment. 

ARTICLE I. 



"We shall study, under this head, first, certain general predispo- 
sitions, unconnected with any morbid state ; second, the effects of 
disease in facilitating the occurrence of fractures ; and, lastly, the 
immediate or determining causes. 

§ I. — General Predispositions. 

The general predisposing causes of fractures are connected with 
the influence of age, sex, and season ; to which must be added those 
marked tendencies which exist in some parts of the skeleton. 

2 (17) 



18 A TREATISE ON FRACTURES. 

(1.) Influence of age. — Fractures have been observed at all times 
of life, from the intra -uterine period to extreme old age, but by no 
means with the same degree of frequency; and Boyer has shown that 
in infancy the bones, being more flexible, escape fracture more easily, 
while in advanced life they arc broken with far greater readiness. But 
these data are vague, and seem, moreover, to rest on theories rather 
than "ii facts. In order to establish the facts at once, I have brought 
forward the registers of the Hotel-Dieu for the space of eleven years, 
from 1806 to 1808, and from 1830 to 1839 ; thus obtaining a suffi- 
ciently imposing total of 2377 fractures, classed according to age. 
I add, for greater clearness, a column showing the mean of the frac- 
tures furnished by every year of life in the corresponding periods : * 



From 2 to 5 years, 


13 fractures. 


Annual mean, 


4 


" 5 " 15 


" 


101 


" " 


10 


" 15 " 25 


" 


289 


" " 


29 


" 25 " 60 


" 


1488 


" " 


42 


" 60 " 70 


u 


316 


a it 


31 


" 70 " 75 


" 


103 


a a 


20 


" 75 " 80 


it 


51 


" " 


10 


" 80 upwar 


ds 


16 


" " 


lor 2 



According to this table, it is seen that fractures occur most fre- 
frequently in subjects of from twenty-five to sixty years of age, 
becoming more rare above and below these limits, as we depart from 
them respectively ; so that as regards the rarity of fractures, the 
extremes of life approach one another : the first period (from two to 
five years) exceeding the last, (above eighty years,) and the fractures 
occurring in equal number in each year of these two other periods : 
viz., from five to fifteen years, and from seventy-five to eighty. 
This result, undoubtedly quite a curious one, still by no means indi- 
cates the real influence of difference in age ; to obtain this we must 
compare, for each period of life, the number of fractures with the 
number of the population. This I have attempted, using the tables 
of the Annuaire des Longitudes ; and the aspect of affairs is thus 
totally changed. Thus, for example, to the period of from five to 
fifteen years belongs nearly one-fifth of the entire population, while 
this same period furnishes hardly more than one twenty-third of the 
fractures. At fifteen years the predisposition suddenly increases ; 
it remains almost the same up to twenty-five years, receiving then a 
new increase quite as sudden as the first ; after which it takes but 
gradual steps up to sixty years ; so that the two periods, for instance, 
from twenty-five to thirty years, and from fifty-five to sixty, giving 
a nearly equal number of fractures, the latter is under the influence 

Etudes Statistiques sur les Fractures; Annates d' Hygiene Publique, tome 
xxii. There have occurred in this work some errors in the figures, which I have 
taken care to correct here. 



A TREATISE ON FRACTURES. 19 

of a predisposition nearly double that of the former, since as many 
fractures occur in a population less by almost one-half. 

But beyond sixty years, there appears quite an unexpected result. 
The number of fractures suddenly diminishes in the same ratio as 
that of the population ; so that the predisposition, which till then 
has been constantly increasing, remains afterwards almost stationary ; 
a given number of old men, as from seventy to eighty years, for ex- 
ample, affording a proportion of fractures not sensibly greater than 
an equal number between fifty-five and sixty. Above eighty years, 
the greater rarity of fractures becomes quite manifest, even deduct- 
ing from the sum of the general population of that age the number 
of the indigent admitted into the two hospitals for the old. 

So much for advanced age. Early infancy offers also, in this 
point of view, singularities hitherto unnoticed. From a resume of 
four years' experience at the Hopital des Enfants, it appears that of 
seventy-five fractures observed in patients aged from two to six years, 
there were, — 

Between 2 and 3 years - -20 

Between 3 and 4 years ------- 21 

Between 4 and 5 years --------6 

Between 5 and 6 years - - - - - - -13 

Between 6 and 7 years 15 

And the number rests stationary during the following years, up to 
the tenth or twelfth. Likewise I found, having undertaken the duties 
of this hospital in the vacation of 1838, that of ten fractures four were 
in children between two and three years old, and six only in children 
between five and fourteen. Children below the age of two years not 
being admitted into the hospitals, I ignore statistics concerning them ; 
but, at any rate, fractures appear to be quite common, relatively 
speaking, from two to four years of age — very rare from four to five ; 
after which, as stated, the proportion increases year by year. 

If, then, only the absolute number of fractures be considered, it is 
from four to five years of age that they are rarest, and from twenty- 
five to sixty that they are most common. 

If we compare this number with that of the population, it is still 
the period from four to five years of age that affords fewest cases of 
fracture; but the one which presents most is from fifty -five to eighty. 

If, now, we would ascertain why the facts should be as given above, 
we may suppose that infants from two to four years old, not as yet 
walking steadily, are liable to frequent falls, the effect of which is 
severe upon bones still of slight strength. After the fourth year, these 
two causes are less efficient, but are soon replaced by others, as the 
games, running, scuffling, etc. of children. At puberty are added 
to these the learning of trades, and from twenty-five to forty years, 
the fully developed muscular power of the man ; after forty years, 



20 A TREATISE ON FRACTURES. 

t he degeneration of the skeleton ; and if this last and strongly-marked 
predisposition to fracture does not increase their number from fifty - 
five to eighty years, and even if, later in life, that number diminishes, 
it is 1 (ccause the debility of age exempts from the exciting causes, 
active labor, quarrels, fights, etc. 

It may be seen that in this enumeration external causes are pro- 
minent, and that the fragility of the bones acts only in very early 
and very late life. Boyer thought that the bones of the old became 
more fragile by the increase of their earthy salts. According to 
well-known analyses, it is, on the contrary, proved that where the 
animal matters predominate the bones are more easily broken ; and 
those which most resist fracture are the compact bones of adults. 
The fragility of the bones of some old men depends on a different 
cause : namely, an affection of the osseous tissue, enlarging the canals 
and thinning the walls of the diaphyses, thus increasing till finally 
the cells of the spongy tissue are made undistinguishable. These 
lesions I have described somewhat in detail in my Anatomie Ghirur- 
gieale, and they have led me to the following triple conclusion, since 
confirmed by my researches at Bicetre : — 

There are persons whose skeletons undergo hardly any modifica- 
tion in advanced life ; and some even in whom the compact tissue 
becomes denser, and as it were eburnated ; these are as little liable 
to fracture as adults. 

In others, the absorption is limited to thinning of the spongy tis- 
sue ; perhaps this is more commonly the case, and hence the large 
proportion of fractures of the ribs, cervix femoris, cervix humeri, etc. 

Finally, in a still smaller number of cases, the absorption affects 
all parts of the skeleton, reducing the walls of the diaphyses to the 
thinness of pasteboard, or even less ; softening the spongy tissue so 
that it is crushed by the fingers ; and here fractures of every kind 
occur from the slightest causes. But the rarity of this affection for- 
bids our considering it as a normal state, and I shall speak hereafter 
of its nature. 

(2.) Influence of sex. — Men are more subject to fractures than 
women ; the proportion was as five to two in my cases at the Hotel- 
Dieu. But this result, true in general, is variously modified by dif- 
ferences in the period of life. Thus I found, for the age of two to 
five years, the number of girls affected with fracture to be nearly 
double that of the boys ; the latter, on the contrary, were at least 
three times as numerous as the girls, between the ages of five and 
ten ; and the proportion went on increasing in the succeeding periods, 
till in that between fifteen and twenty years there were 136 males to 
seventeen females, or about eight to one. Afterwards it diminishes, 
as up to the age of forty-five there were three, or perhaps four, fractures 
in men to one in a woman. This period passed, it still goes down, 
so that from seventy to seventy-five years the numbers are equal for 



A TREATISE ON FRACTURES. 21 

the two sexes; and beyond seventy-five years there are nearly double 
as many fractures in women as in men — infancy and old age again 
approaching one another. 

Hence the influence of age differs in the two sexes ; if it be true, 
or nearly so, that the man of seventy or eighty has the same pre- 
disposition to fracture as the man between fifty-five and sixty, this 
law is evidently incorrect as regards women, in whom the number of 
fractures sensibly increases from fifty-five to eighty in proportion to 
the population. To some degree, these differences can be explained; 
in early infancy, by the slower development of female children, which 
renders their skeletons less solid ; a little later, by the differences in 
education between boys and girls ; still later, by their differences of 
occupation; and finally, in the period of old age, the ravages of time 
are more rapid and marked in the female, and exert more influence 
in the degeneration of her osseous tissue. 

(3.) Influence of the seasons. — A. Pare has stated that the bones 
were more fragile during the winter, and in time of frost — a theory 
which I do not think tenable ; and modern surgeons have ac- 
cepted his assertion, without ever verifying it. It much needs proof, 
nevertheless, that the difference between winter and summer is as 
great as one would be led to suppose; and by the most favorable 
estimate, taking the figures of my eleven years en masse, and con- 
trasting in each the four months from December 1st to March 31st 
with the other two similar periods, an excess of one-eighth in the 
sum of the fractures in the winter season over that in the summer 
is the utmost that I have found. Dividing the year into four periods, 
of three months each, the proportion is still less; as, for example, 
from 1834 to 1837, the spring months presented more fractures than 
any others. Lastly, if we contrast the single months one with an- 
other, we frequently find a summer month equal to, if not exceeding, 
a winter month ; thus, in our eleven years, February showed con- 
stantly fewer fractures than June or October. 

To weigh the circumstances carefully, falls are doubtless more fre- 
quent in the winter, the ground being slippery ; but these falls are 
generally slight, while in mild weather, when masons, carpenters, 
etc. resume their labors, the falls which occur are apt to be from 
heights, and hence far more dangerous. And this is not mere hypo- 
thesis ; we shall see, in fact, that among adults so employed as many 
fractures are sustained in summer as in winter, while to weak old men 
the latter is the more perilous season. For greater simplicity, I have 
divided the year into only two periods ; the result is as follows : — 



Ages. 




Winter. 


Summer. 


Proportions. 


From 2 to 15 years, 


47 


fractures. 


66 


71 to 100 


" 15 to 25 " 


126 


« 


163 


77 to 100 


" 25 to 45 " 


432 


" 


429 


equal 


" 45 to 55 " 


225 


" 


188 


120 to 100 


" 55 to 80 " 


422 


« 


272 


155 to 100 


Above 80 " 


8 


" 


8 


equal 



'22 A TREATISE ON FRACTURES. 

As regards adult age and extreme old age, this table needs no com- 
ment ; evidently between twenty-five and forty-five years all seasons 
are equal; and on the other hand, above forty-five years, winter 
makes its influence felt more and more as age advances. Only after 
the eightieth year the occurrence of fractures according to the sea- 
sons seems to obey exceptional laws. 

But what has doubtless struck the reader, is the singular difference 
between earlier and later times in the opinions entertained on this 
point. In infants and children, not only are fractures not more fre- 
quent in the winter, but they are notably fewer than in the summer. 
1 have met with the same difference in the Hopital des Enfants; where, 
of 137 fractures observed from 1834 to 1837, eighty-four occurred in 
the warmer six months of the year. How shall we explain a fact so 
new, and so contrary to received opinions ? Is it not because in 
winter children are carefully kept in the house, while in summer, in 
running about and playing, they are more exposed to the causes of 
fracture ? 

However this may be, the winter season is not really unfavorable 
except to the old ; and as the female skeleton undergoes a more 
marked deterioration in advanced age than the male, we should pre- 
sume a priori that a notable proportion of fractures occurring in 
cold weather would be sustained by women. This conjecture is con- 
firmed by the following statistics : — 

In summer ... 819 men - 297 women 

In winter - - 861 men - - 400 women 

Hence winter, adding but one-sixteenth to the number of fractures 
in the male sex, adds one-third to those in the female ; and I am 
satisfied, besides, that this increase affects mainly old women ; so 
that the number of fractures in women over fifty years of age is in 
winter nearly double what it is in summer. 

(4.) Predispositions in certain parts of the skeleton. — It is not 
very long since the attempt was first seriously made to draw up the 
statistics of fractures, in order to appreciate better than from hypo- 
theses the degree of predisposition of each bone. Desault conceived 
the idea, but never carried it out. I have mentioned, in the memoir 
already quoted, the partial attempts made at the Hotel-Dieu, in 
Paris; the more extended tables of Martin, for twenty years, 
from the Hindoo Hospital, at Calcutta ; of Lonsdale, for six years, 
from the Middlesex Hospital, London ; to which must be added an 
analogous work by Wallace, for the Pennsylvania Hospital, in Ame- 
rica, from its foundation in 1751 down to 1838.* Unfortunately, 

* Bee "The Quarterly Jowrnal of the Calcutta Med. and Phys. Society" for 
January, L838; Lonsdale, op. cit., p. 18; "The British and Foreign Medical 
1!> view" for July, 1838. 



A TREATISE ON FRACTURES. 



23 



we are not quite certain of the real value of these documents ; I had my- 
self conceived the idea of bringing to bear on this subject the regis- 
ters of the Hotel-Dieu since 1790, when I was foiled by the inaccu- 
racy of the diagnoses there recorded. I have confined myself, 
therefore, to the examination of eleven years, during which, as an 
exception, the registers gave the diagnosis on admission, subject to 
that of the attending surgeons on duty ; yet even here in some cases 
the designation of the bone fractured has been omitted, and in others 
the diagnosis is wanting in precision. Apart from these defects, I 
believe the following table may be regarded as more exact than any 
of the others: — 



Fractures of the skull 53 

" " upper maxillary and malar bones - 3 

" " nasal bones 12 

" " lower maxillary bone 27 

" " vertebrae 11 

" " pelvis -.----_ 7 

" " sacrum ------ . 1 



" coccyx 

" ribs 
a costal cartilage 
the sternum 



Total of fractures in the trunk 



379 



Fractures of the clavicle 

" " " scapula 

" " " shoulder ------ 

" " " cervix humeri - 

" " " humerus ----- 

" " " elbow . . . - - 

" " " olecranon 

" " " forearm - - - - 

" " " ulna ------ 

" " " radius 

" " " carpus 

" " " metacarpus - 

" " M phalanges of the fingers 

Total of fractures in the superior extremities 



925 



Fractures of the cervix femoris 104 

femur 199 

knee 5 

patella 45 

leg 515 

tibia 29 

fibula 108 

foot 9 

toes 10 



Total of fractures in the inferior extremities 



1024 



2-4 A TREATISE ON FRACTURES. 

Tims, then, arc classified 2328 subjects affected with fractures of a 
Bingle bone, or of several parallel bones, as the ribs, bones of the 
leg or forearm, etc. To these add thirty other cases of fractures, 
more numerous or otherwise combined, involving both legs, or the 
leg and the thigh, etc., a species of complication to which I shall 
recur in connection with multiple fractures ; and there will remain of 
our whole number nineteen fractures, the seat of which is not defined. 

If, comparing this table with the more authentic of the other do- 
cuments, we seek to deduce some results, we may say at once, in ge- 
neral, that fractures are more common on the right than on the left 
side of the body ; undoubtedly because, the right side being more 
robust and more practised, we instinctively put it forward, whether 
for attack or for defence. The proportion is variable, and the excess 
in favor of the right side is not more than one-quarter. 

If we consider separately the bones of the trunk and those of the 
members, we find fractures of the former notably rarer than those 
affecting the upper extremities, and these again less common than 
those of the lower extremities. 

Boyer thought that the more superficial bones were more liable to 
fracture than the rest ; this is not true except for the tibia, which, 
indeed, is more frequently broken than any other bone. But close 
upon the tibia comes the femur, one of the least superficial bones ; 
and among the rarest fractures are those of the acromion, olecranon, 
calcaneum, and sternum ; all of which are just beneath the skin. 
Hence it is the long bones which are oftenest broken ; and this law 
holds good in the trunk also, in the ribs. Again, the tibia and the 
radius, which, in falls on the feet or hands, sustain mainly the weight 
of the body, exceed almost all the other bones in the frequency of 
their fractures. 

Quite recently it has been stated that fractures of the diaphyses 
occur more usually in adult age, and intra-articular fractures chiefly 
in the old.* But this assertion is much too general, and can only 
be sustained in reference to fractures of the cervix femoris. There 
are, indeed, fractures which are more common at some periods of life 
than at others ; those of the cervix humeri and cervix femoris, 
intra or extra-capsular, are, as it were, the painful appanage of 
advanced years, while fractures of the shaft of the femur, common 
to all ages, occur with far more frequency in youth than at any other 
time of life. Others are quite unequally divided between the sexes ; 
women sustaining a large proportion of the fractures of the cervix 
femoris, of the cervix humeri, of the carpal extremity of the radius ; 
while it is but rarely that we are called upon to treat, in them, frac- 
tures of the nasal or maxillary bones, of the metacarpus, or of the 
phalanges. The seasons have also their effect in favoring the occur- 

* Did. des Dictionnaires de MMeczne, art. Fractures. 



A TREATISE ON FRACTURES. 25 

rence of certain fractures ; but the study of these curious etiological 
conditions may be better carried out with that of each particular 
fracture. 

§ II. — Of some Affections predisposing to Fracture, 

All these affections may be arranged under two heads, according 
as they render the osseous tissue more fragile, or increase inordi- 
nately the power of the muscles acting on the bones. Cases are re- 
corded of fracture due to violent convulsions ; but I shall return to 
this point in speaking of fractures by muscular action, and treat 
here only of affections impairing the cohesion of the osseous tissue. 

These are, first, such as attack the entire economy, and for this 
reason are called diatheses or cachexies. Such are scurvy, gout, 
cancer, syphilis, scrofula, and rachitis. 

(1.) Scurvy. — Every year, in the spring, scurvy appears at Bicetre ; 
I have seen it in several cases of fracture, but never saw a fracture 
attributable to it. Still, when its signs are well marked, its effect 
on the bones is manifest. In the epidemic which in 1798 prevailed 
at the Hopital Saint Louis, Poupard and Saviard found in several 
cases the bones softened, increased in volume, easily crushed, and 
the epiphyses readily separated. In a very young child, examined 
by Saviard, the softening was confined to the two femoral bones. M. 
A. Berard has cited also the case of a female patient at la Salpe- 
triere, in whom scurvy had acted upon a portion only of the skele- 
ton ; the bones of one lower extremity being found infiltrated with 
blood, and easily broken by the slightest touch.* 

(2.) G-out. — Various authors have mentioned gout as predisposing 
to fracture ; yet to support this assertion I have been able to find 
but two instances, and those by no means conclusive. There is, first, 
the account given by Sarrazin, of a man, aged 60, affected for two 
years with an arthritis pituiteuse in the right shoulder and elbow- 
joints, who broke his right humerus in putting on his glove; the frac- 
ture was double, one point being four or five fingers'-breadths below 
the shoulder, and the other lower down, near the elbow. No callus 
was formed, and the patient dying two months afterwards, the hu- 
merus was found completely carious ; in other words, softened, and 
easily crushed with the finger. He had denied ever having had 
syphilis, f 

The second case was published by Kruger-Hausen. A woman, 
aged 76, had suffered for several years from gouty and shooting pains 
in the limbs, which kept her quite bent up. One day, wishing to sit 
down, and feeling for her chair with the right hand, she broke the 

* M6m. de V Acad, des Sciences, 1699, p. 169; Saviard, Nouv. Recueil de 
Observations, obs. 81 ; A. Berard. art. Fractures, du Dictionnaire en 30 volumes, 
t Fab. Hildani, centur. li, obs. 66. 



26 A TREATISE ON FRACTURES. 

cervix humeri of that side. At the end of six weeks, consolidation 
being nearly completed, she stepped on her dress, put out her left 
hand to disengage it, and broke the left humerus at the correspond- 
ing point. From this time she kept her bed ; and again, being 
tm nod in order to receive an enema, a sudden crack announced a 
fracture of the cervix femoris.* 

Even if these two persons were affected with gout, properly so 
called, their ages would still forbid our considering that as the sole 
and real cause of the fragility of the bones. In the Muse'e Dupuy- 
tren may be seen several skeletons of gouty subjects, which have 
suffered anchylosis of nearly all the joints, but not one of which bears 
traces of fracture. M. Mercier, indeed, claims to have observed in 
the bones of old gouty persons a large amount of medullary fat, 
seeming to indicate that this disease favors the occurrence of senile 
atrophy in the skeleton ; but I apprehend this statement to be too 
general, and have not myself seen that the bones of the gouty are 
more frail than those of other subjects. 

(3.) Cancer. — The influence of cancer on the osseous system is 
far greater; but it must be owned that it appears in but a very 
small number of cases, and under conditions as yet but little known. 
I have frequently seen patients die at Bicetre with all the marks of 
the cancerous cachexia, and who besides have come to this hospital 
only after having undergone several operations and as many relapses ; 
but I have seen in none of them this fragility of the bones, which 
has been noticed sometimes in patients apparently in a much less 
advanced stage of the disease. 

The first example of this kind was published in 1723, by J. L. 
Petit. An old woman had long had a cancer of the breast, which 
troubled her only from time to time ; there appeared at the middle 
of the left femur a swelling, involving the whole circumference of 
the bone, with constant pains. In turning herself in bed, she broke 
the thigh, and the pains ceased at once. Similar tumors formed in 
the humerus and clavicle ; these bones were likewise broken, and 
finally the patient died.f 

[James Ring, an Irish shoemaker, aged 35, received a blow with 
a hammer on the left thigh, in the summer of 1855 ; three weeks 
after, lie twisted his leg in assisting to lift a heavy barrel, and 
thought it broken; he lay a month in bed without treatment, then 
walked to one of the college dispensaries. He received here a blister 
and a stimulating liniment, and used these; lay in bed three weeks. 
Nov. 3. He experienced great pain in the evening, and next morn- 
ing found his thigh fractured and much bent, the angle salient 

* Med. Chzrurg. BeobacMungen, von Dr. Kruger-Hausen ; quoted in the 
Jowrncd de Graefe et Walther, tome iii, p. 647. 
f Malad. des Os, 1823, tome ii, p. 363. 



A TREATISE ON FRACTURES. 27 

anteriorly. He was now admitted into the Pennsylvania Hospital, 
and treated by the ordinary means until Feb. 26, 1856 ; then, at his 
urgent request, no union having taken place, the limb was removed. 
A mass of medullary cancer involved the bone at the seat of the 
fracture. The stump healed well for some time, until a fungous 
mass grew from the end of the bone. This fungus was very vascular, 
and repeated hemorrhages from it greatly reduced his strength. Dis- 
ease of the lungs was plainly indicated on physical examination. 
June 3, 1856, he died, and in the stump and lungs were found immense 
deposits of cancerous matter. Other organs healthy.] 

It is not even essential that the fracture should be preceded by the 
local tumor of the bone. Mareschal has given the case of a woman 
of forty-five from whom he removed the mammary gland, and who, 
after cicatrization was completed, felt severe pains all through the 
body ; one day, in turning herself in bed, she broke the femur close 
to its neck. Morand saw a precisely similar instance. In each of 
these cases, death occurring soon after, the femur was found softened 
and carious ; in the first, it is added that the periosteum was de- 
tached, and that the color of the skin was unchanged.* Louis's Case 
is better known. It occurred in a nun, aged 60, whose arm was 
broken by a coachman in helping her into a carriage. No callus 
was formed ; seven months after, while sitting in an elbow-chair, and 
carelessly dropping her hand upon her thigh, her femur was frac- 
tured by this slight shock ; and Louis, struck by this fragility, 
learned at last that the patient had an ulcerated cancer of the breast. 

In these three cases the fractures were not consolidated ; it is im- 
portant to know if non-union is the law for fractures induced by 
cancer. Pouteau has reported a case of exception to the rule. He 
had removed an ulcerated cancer of the breast from a woman, aged 
45. Cicatrization took place wonderfully well ; but at the end of a 
year pains came on in the hips and thighs, so as to compel the pa- 
tient to keep her bed ; a year later, as her servant was moving the 
thigh, the femur gave way with severe pain, soon followed by a con- 
siderable swelling. Pouteau placed her on the use of ice-water and 
pills of butter of antimony ; but a copious salivation obliged him to 
abandon the use of these pills at the end of a month. The consoli- 
dation was not hindered by this, and the patient lived for two years, 
at the end of which time she died of dropsy. f 

Was it here really cancer which affected the bones ? Pouteau says 
himself that his patient had had, several years before the formation 
of the cancer, une humeur rhumatismale, which even attacked the 
two wrists the third day after the operation on the breast. I cer- 
tainly should not say that the presence of a cancer in the economy 

* M6m. de V Acad, de Chirurgie, tome hi, pp. 49, 50. 
f Pouteau, (Euvres Posthumes, tome i, p. 75 et seq. 



28 A TREATISE ON FRACTURES. 

would bo an obstacle to the uniting of a fracture. Dupuytren seve- 
ral times saw fractures consolidated in due time in women who had 
cancer of the breast or of the uterus ; but the question is whether 
callus would form upon the bones made fragile by the influence of a 
cancer elsewhere. 

The earliest autopsies properly made in this kind of fracture were 
those of Dupuytren. In a woman, aged 54, he saw tumors of a 
black, soft, spongy substance, of the size of an almond, seated here 
and there on the femur, and which, when detached, left openings 
leading to the medullary canal. The latter was very large, and its 
walls thin and crumbling. Similar degeneration had occurred in the 
pubis and in the ribs. In another case, a cancerous tumor of the 
size of two fists occupied the seat of fracture, and adhered to both 
fragments ; the other bones were friable, but nowise changed either 
in form or color.* 

Here we see the fragility to be due to two causes — the thinning 
of the bones, and the development of cancerous tumors at their sur- 
face. At other times the degeneration occupies the interior of the 
bones. Thus M. Blandin found the neck of the femur, fractured 
much as in Dupuytren's case, transformed into an osseous shell, in- 
closing a scirrhous mass, compact, creaking under the knife like 
bacon-rind, yellowish on the outside, and reddish toward the centre. 
The compact substance of the femur and of the other long bones 
crumbled into small fragments at the slightest touch, and the medul- 
lary canal contained, in place of the marrow, a matter similar to 
that found in the neck of the bone. The cranial bones were like- 
wise softened.f 

I have seen similar disease among the bones presented to the 
Academy, by Sanson, in 1834. A woman, aged 40, had a cancer 
of the breast, which she dated from seventeen or eighteen months 
previous, and under which she had evidently failed ; there were now 
felt some tumors in the abdomen. In moving in bed she broke her 
thigh ; the interne, in endeavoring to treat this fracture, broke the 
corresponding bone on the other side. Death soon took place, and 
at the autopsy there were found scirrhous masses, some of them soft- 
ened, in the abdominal walls, lungs, liver, etc. The osseous system 
was stuffed with them ; they occupied the substance of the cranial 
bones, and one, the size of a nut, had traversed the entire thickness 
of the os frontis. The spinal column, sawed open longitudinally, 
presented an extraordinary quantity of these masses in the bodies 
of nearly all the vertebrae ; they existed also in the extremities and 
medullary canal of each femur. They seemed to have grown from 
within outward. Where they were most developed the osseous pa- 

* Dupuytren, Lecons Orales, tome i, p. 49 et seq. 
f Gazette des Hopitaux, 1832, tome vi, p. 522. 



I 



A TREATISE ON FRACTURES. 29 

rietes were proportionally thinned ; and at these points, thus weak- 
ened, the fractures had taken place. M. Cruveilhier has had dif- 
ferent parts of this skeleton represented in connection with other 
analogous observations.* 

To sum up, the fractures which occur almost spontaneously in can- 
cerous subjects would seem to be, in the majority of cases, due to 
cancerous degeneration of the bones themselves, and are then abso- 
lutely incurable. In some exceptional cases, the bones alone seem 
affected by what resembles senile atrophy ; of this Rumpelt has cited 
an instance : — A woman, aged 60, had had induration of the mam- 
mary glands for four years. Flexing the right thigh in her sleep, 
the femur gave way in two places. Death ensued soon after, and then 
it was found that all the true ribs were fractured ; but no trace of 
cancerous deposit was detected in the skeleton. f Then the callus 
may be regularly formed, as probably occurred in Pouteau's case. 
I would add that this atrophy may be in some sort partial or local. 
Thus, in a woman whose breast I removed for cancer, and who died 
from its return, I found the thickness of the subjacent ribs diminished 
to about two millimetres (one-fifteenth of an inch.) They were also 
softened, gorged with blood, and easily bent or broken, but otherwise 
without any trace of degeneration. The ribs on the other side, and 
the rest of the skeleton, were in a perfectly normal state. 

(4.) Syphilis. — Like cancer, syphilis seems sometimes to exert an 
influence on the bones, the more mysterious from its rarity, and from 
the fact of a majority of patients escaping it. Attention was first called 
to this subject by Marcus Donatus. He gives the history of a Portu- 
guese, affected for several years with constitutional syphilis and to- 
phaceous tumors of different bones, which seemed at last to yield to 
mercurial frictions. One day, throwing half an orange at a comrade, 
he fractured the right humerus. Consolidation was hardly effected, 
when, in extending his left arm from the bed to reach the chamber, 
the humerus on that side gave way also ; this united with equal readi- 
ness. \ Since, then, facts of this, kind have multiplied; cases are 
even cited of non-union attributed to syphilis, in which consolidation 
followed the exhibition of mercury. I shall recur to this when 
speaking of treatment ; merely adding, for the present, that the ana- 
tomical state of bones thus weakened by syphilis is as yet unknown, 
and that in old men it acts mainly by favoring atrophy of the skeleton. 

(5.) Scrofula. — Fragility of the bones from this cause is still more 
rare, and I have hardly been able to collect any instances of it. 
Dupuytren has recorded the case of a little girl of eight months, of 
scrofulous constitution, who suddenly, and without previous complaint, 

* Anatomie Pathologique du Corps Humain, livraison 20, pi. i. 

t Gazette Jl^dicale, 1835, p. 641. 

t M. Donati, Be historid medicd mirdbili, Lib. sex; Lib. v, cap. i. 



30 A TREATISE ON FRACTURES. 

waked in the night with loud cries. It was considered an attack of 
flatulent colic; but after three days her mother detected a swelling 
at the middle of the thigh. The surgeons consulted gave various 
opinions ; some considering it a mere curvature of the bone, others 
a swelling caused by cold. Finally the fracture was recognized, and, 
under Dupuytren's treatment, united at the end of five months.* 

Goodwin's case is quite a remarkable one. Mary Bradcock, aged 
32, of relaxed fibre, pale complexion, and brown hair, having always 
enjoyed pretty good health, temperate in her mode of life, and never 
having used mercury, felt, in the winter of 1783, pains in her limbs. 
These she attributed to rheumatism ; but one day, having struck her 
foot against a brick, she was not a little surprised at finding a frac- 
ture close to the ankle. Before her recovery from this accident was 
complete, she became pregnant for the eighth time ; and one day, as 
her husband was helping her out of bed, she broke her left thigh 
without any violence whatever. Her accouchement was favorable : 
but soon afterwards she fractured her left arm by merely putting it 
over the neck of a person who was helping to lift her. Afterwards, 
while in bed, she broke her right thigh, first near the hip, and some 
time afterwards lower down, near the knee ; then the clavicle ; then 
the right arm ; and again the right femur, hardly cured of its two 
former fractures — in all, eight fractures in the space of eighteen 
months, without any evident cause. But before the occurrence of 
each fracture, she experienced constantly, during several weeks, a 
considerable pain at a certain part of the bone, which went on in- 
creasing till the fracture took place, and then disappeared for a few 
days. At the time the observation was made, she complained of a 
pain a little above the elbow, threatening her with a ninth fracture. 
For each fracture there was employed merely a light bandage. The 
callus formed in five or six weeks. Dr. Hamilton, who carefully ex- 
amined her, found nothing abnormal in the perspiration or urine. 
Her complexion indicated a strumous tendency ; and, indeed, several 
of her family, even of her own children, were affected with scrofula ; 
but she herself had never suffered from it.f 

Would these facts sufficiently test the influence of scrofula in pro- 
ducing fractures ? I would hardly affirm it. As to the first case, a 
single fracture proves but little; as to the second, fractures so nume- 
rous seem to me to prove too much ; a fragility so remarkable could 
not but be attributed, in my opinion, to a rachitic constitution. 

(6.) Rachitis. — Rachitis is perhaps the affection which most of all 
predisposes to fracture ; but I do not limit the use of this name to 
the rickets of children ; we must trace it in adult age and senility, 

* Lecons Orales de Dupuytren, tome i, p. 43. 
t Journal de M6decine, tome lxxvi, p. 81. 



A TREATISE ON FRACTURES. 31 

to get a complete idea of it, and must besides clearly distinguish its 
periods, to comprehend well its effects. 

Rachitis begins by a peculiar state of the bones, which I can com- 
pare to nothing better than to the red softening induced by inflam- 
mation ; the bone is then lighter and more fragile, and fractures 
occur very readily. At a more advanced period, the salts of lime 
diminish more and more, and with them also the solidity of the bone, 
which is at some points nearly carnified, bending and curving instead 
of breaking ; but sufficient fragility remains in portions of the skele- 
ton to give rise to fractures as well as curvatures. Finally, the pro- 
gress of the complaint being checked, the osseous tissue ordinarily 
regains, little by little, its former solidity, or even passes into the 
state of eburnation, making fractures as difficult, or more so, than in 
the normal condition; or perhaps restoration does not occur, the 
bones remaining weak, thinned, with enlargement of the cells of the 
spongy tissue and of the medullary canals in the diaphyses ; in which 
case, not only are fractures more common, but sometimes the atrophy 
of the bone goes so far that consolidation takes place slowly and 
with difficulty, or not at all. 

Instances of multiplied fractures in rachitic children are abundant ; 
but it must be remarked that they rarely occur before curvature — 
doubtless because the children, being infirm, are kept in bed ; and 
that they mostly take place during convalescence — that is to say, 
when the twisted bones have acquired firmness enough to allow of 
walking and exercise. A little boy, six years old, whose father was 
healthy, but whose mother was rachitic, and whose legs and thighs 
had been distorted in early infancy by rachitis, fell, in playing. He 
sustained a fracture of the left humerus, unaccompanied by pain, 
and very regularly consolidated in one month. A year after, in 
playing, he broke the left femur at the middle, likewise without pain; 
union ensued in forty days. Three months went by, and he was en- 
tirely cured, when, in leaning from his bed to pick up some object 
from the ground, he again broke the same thigh, but this time at the 
lower third. Forty days again sufficed for union ; but the child's 
enfeebled health obliged him to go on crutches. Finally, at the age 
of ten, one of his crutches slipping, he fell and broke the right femur 
at the middle. It was for this fracture that he entered the Hospital 
des Enfants, where I was on duty in the summer of 1838, and where 
I recognized the traces of the preceding ones. This appeared to be 
transverse ; it caused no more pain than the others, and was per- 
fectly united by the forty-second day. He had thus had in four 
years as many fractures, arguing badly for his future prospects. 

Jacquemille has traced much further a patient of the same class, 
born of healthy parents, but affected from his first year with general 
rachitis, which had flattened his ribs, distorted his spine, and curved 
all the long bones except the humerus. He could not walk till five 



32 A TREATISE ON FRACTURES. 

years old, and remained always excessively small and feeble. To- 
ward the age of twelve, in mounting a wood-pile, he fell and broke the 
right arm at the middle. The fracture was simple, and united per- 
fectly. At fifteen, trying to get up behind a carriage, he lost his 
footing, and fractured both thighs ; which uniting with deformity, he 
was permanently crippled on the right side. At seventeen, he broke 
the left arm. At twenty-eight, he broke the left thigh, at a different 
point from before. Finally, at thirty-two, he again broke the right 
thigh, likewise at a new point. The case was not observed further.* 

In the Musde Dupuytren (No. 516) may be seen the skeleton of a 
child six or seven years old, affected with general rachitis. It presents 
fractures of two ribs, of both clavicles, of both ulnse, of both bones of 
both legs, and lastly, of the right thigh in two places — in all, twelve 
fractures. Lonsdale saw a young girl almost all whose bones were 
attacked with rachitis, and who had successively twenty-two frac- 
tures, occurring from the slightest causes. In all consolidation took 
place in the usual time. In the London Medical Gazette is given 
the history of another young girl, who, between the third and four- 
teenth years of her life, sustained thirty-one successive fractures, all 
in the long bones of the extremities; and, what is remarkable, the 
first occurred during the first stage of rachitis; viz., before the ap- 
pearance of any curvature.f Lastly, it is said that Esquirol had in 
his anatomical collection the skeleton of a rachitic female, nearly all 
whose long bones had been broken in two, three or four points of 
their extent. There were thus counted more than two hundred frac- 
tures, all more or less united.J 

In adults, rachitis rarely reaches the stage of carnification and 
curvature of the bones ; still, this is known to have occurred in seve- 
ral instances. The most celebrated of these is that of the woman 
Supiot, in whom nearly all the bones had undergone the strangest 
distortions ; even at the autopsy, they could at many points be bent 
without breaking, although at others they displayed extreme fragility. § 

But it is more common to see rachitis arrested at the period of red 
softening, which perhaps it never passes in individuals over forty years 
old. Then we see the spongy tissue broken down, the spine curved, 
the cervix femoris depressed, flattened, kneaded, as it were, by the 
pressure of the cotyloid cavity, or by its own pressure on the ace- 
tabulum, etc. ; and hence the various deformities of the articulations 
in some old persons ; but the diaphyses, remaining inflexible, are 
broken by the least shock. I would not imply by this that the spongy 
bones better resist fracture ; and it is well known that the cervix 

* Journal de Midecine, tome lxxvii, p. 267, and lxxxiv, p. 216. 

t London Medical Gazette, 1833, vol. xii, p. 366. 

% Art. Fractures, Diet, en 30 volumes. 

\ Morand, Opuscules de Chirurgie, part ii, p. 224. 



A TREATISE ON FRACTURES. 33 

femoris, which is in old people first affected with softening, is also in 
them the portion of the skeleton most frequently broken. 

I think it very likely that the fragility of the bones said to be 
caused by the influence of syphilis, scrofula, or gout, belongs to the 
rachitis of adult age and senility ; it shows itself besides in cases 
where none of these causes can be imputed. Saviard has given the 
history of an unmarried woman, thirty years old, admitted into the 
Hotel-Dieu for excessive pains in the whole body, without fever, and 
with no symptom of syphilis or of any other disease. When she 
had been in bed three months, unable to walk, her bones broke so 
easily that she could hardly be touched without causing a new frac- 
ture. At the autopsy, fractures were found in the thighs, legs, and 
arms, the clavicles, the ribs, the vertebrae, etc. ; all the bones were 
filled with a reddish marrow, and crumbled , under the fingers.* 

It would be superfluous to cite instances of the fragility of the 
bones in old people, and I will merely mention the case of Seraphin, 
the director of the Ombres Chinoises, which I have given in my Ana- 
tomie Chirurgicale, and that of a woman at la Salpetriere, in whom 
M. Cruveilhier found at the autopsy fractures of the right leg, left 
femur, and right radius, and two or three fractures in nearly all the 
ribs.f The state of the bones was like that observed by Saviard; 
like that in infantile rachitis, at the stage called by M. J. Guerin 
rachitic consumption of the skeleton ; like, finally, though in a less 
advanced stage, that found in old people affected with what is com- 
monly called senile atrophy. 

As local predisposing causes, writers have mentioned caries, ne- 
crosis, tubercle, ulceration from the pressure of an aneurism or of a 
malignant tumor, the development of hydatids in the bones, osteo- 
sarcoma, etc. Doubtless all these affections tend to lessen the solidity 
of the bones, and hence favor fracture ; and it would be easy to 
adduce instances to prove this ; but the fractures occurring under 
such circumstances would be, as it were, merely incidental to the 
principal disease ; this requiring all the attention of the surgeon, 
while they would be better placed under the head of complications. 

But a much more frequent cause, and one by far too much neglected, 
is local inflammation of the osseous tissue. I designate thus, by con- 
jecture, an affection manifested generally by dull pains, referred by 
the patient to a previous contusion, or to an attack of rheumatism ; 
these are rarely severe enough to excite general reaction, and attract 
little attention, until at last, by slight violence, a fracture is caused 
at their seat. I have seen a young man of twenty, strong and of 
good constitution, fracture the femur by a fall on perfectly even 

* Saviard, Nouv. Recueil d'Obs. Chir., obs. 62. 
f Cruveilhier, Essai sur VAnat. Pathol., tome i, p. 193. 
3 



34 A TREATISE ON FRACTURES. 

ground. For several weeks he had suffered, at the exact point of 
the fracture, pains which he attributed to rheumatism. 

The majority of fractures of long bones by muscular action are 
brought on, so to speak, just in this way. Nicod has cited two re- 
markable instances of this. A journeyman joiner had felt for a month 
severe rheumatic pains in the left arm; a fracture occurred from 
his resting his left hand firmly on the crank of a windlass, which he 
was turning with his right. A laborer broke his right arm in throw- 
ing a stone ; he stated that he had always enjoyed good health till 
a month previous, when pains had come on in this arm, so severe as 
almost to prevent his working ; but he had had no fever, nor lost his 
appetite for a single day.* I shall cite similar facts in connection 
with fractures of the patella ; and whenever we are called upon to 
apply great force to the bones, as in reducing old dislocations, I regard 
it as an important precaution to ascertain first that the patient has 
not experienced steady pains in the member luxated. 

Atrophy of the bones, with diminution of their thickness, often 
attends unreduced dislocations ; but it oftener results from the immo- 
bility of paralysis. Thus the want of muscular action predisposes 
to fracture by enfeebling the structure of the bones ; on the other 
hand, an excess of it leads to fracture by subjecting the skeleton to 
violence beyond its natural powers of resistance. Epileptics, during 
their attacks, and persons subject to violent and repeated convulsions, 
are naturally exposed to fractures from muscular action ; but here 
the predisposition becomes blended with the immediate causes, to 
which reference will be made directly. 

§ III. — Of the Determining Causes of Fractures. 

The immediate causes of fractures are of two kinds; external 
violence, and muscular action. A case has been reported of fracture 
of a rib, attributed to the beating of the heart ; but the reality of 
this as the cause was rather presumed than ascertained; it will be 
again referred to at the proper time and place. 

Fractures by external violence are much the most common. When 
the bone yields at the point where the force is applied, we say the 
fracture is direct, or by direct violence; when at some other point, 
it is said to be by contre-cowp, counter-stroke, or indirect violence. 
But it is not always easy, in practice, to determine whether a 
fracture is caused by direct or indirect force ; and although blows 
generally break the bone at the point struck, and falls oftener act 
by counter-stroke, yet there are so many exceptional cases, that the 
external causes of fracture cannot be classed otherwise than by their 
presumed order of frequency. Falls, then, without doubt take the 

* Annuaire des Hopitaux, Paris, 1819, p. 494. 



A TREATISE ON FRACTURES. 35 

first place; then direct blows, powerful pressure, excessive twisting, 
bending or pulling; to which must be added some other causes, very 
rare, and each requiring separate consideration. 

Falls may take place upon the ends of the feet or of the hands, 
on the heel or the wrist, on the knee or the elbow, on the hip or the 
shoulder, on the head or the pelvis ; in fine, on almost any part of the 
body; they may occur from various heights, upon a surface hard or 
soft, smooth or rugged; or there may be something like a succession 
of falls, as for instance when a mason, tumbling from a very high 
scaffolding, strikes a beam, breaks it, and then falls to the ground. 
Nothing is more variable, more capricious, so to speak, than the 
effect of falls. There appeared lately in the journals an account of 
a man falling in a quarry from a height of about twenty feet, without 
breaking any bones ; while a few months ago an old man at Bicetre, 
being pitched from the second story, sustained fractures of nearly 
every bone in his skeleton; — among others such a crushing of the 
dorsal vertebrae, that the lungs could be removed through the open- 
ing thus made. And who does not know that a mere fall on level 
ground may give rise to fracture of the leg, thigh, arm, or clavicle? 
It seems generally as if the force of a fall, in order to cause a frac- 
ture, needed also a certain action of the muscles, fixing the bones as 
levers ; this is especially marked in fractures by indirect violence ; 
thus it is very difficult to produce such fractures on the dead sub- 
ject, however we may vary its falls ; and the privilege of drunkards, 
who so often fall with impunity, has become proverbial. 

It is certain that many direct fractures are caused by falls ; thus 
a fall on the heel breaks the calcaneum ; on the knee, the patella ; 
on the hip, the trochanter; on the shoulder, the cervix humeri; on 
the chest, the ribs, etc. But perhaps more commonly the part 
struck remains sound, and the bone is broken at some other point, 
by counter-stroke; thus by falling on the feet there may be caused 
fracture of the leg, of the thigh, or even of the pelvis ; a fall on the 
hand may break the radius or the humerus; on the shoulder, the 
clavicle; or, any one point of the chest being struck in falling, frac- 
ture of the ribs may occur at a point more or less distant. The 
usual theory of indirect fractures of long bones is very plausible; the 
bone being fixed at one extremity against the ground, the weight of 
the body acts on the other end, and it is thus subjected to two op- 
posing forces, tending to increase its natural curvature; it then 
breaks like a bow too forcibly bent. There is doubtless some truth 
in this comparison; but it must not be supposed that the circum- 
stances always follow this regular plan, and that forces apparently 
similar, even acting on the same bone, will always break it at the 
same point, viz., that of its greatest curvature. We see falls on 
the shoulder break the clavicle at the middle, or near the sternum, 
or near the acromion. So also the tibia may give way at any point 



36 A TREATISE ON FRACTURES. 

in its length, though most frequently in its lower half. In the 
radius, fracture almost always occurs near the wrist. The weak- 
ness, natural or acquired, of different portions of bones, the varying 
obliquity of the fall or counter-stroke, and other circumstances more 
easily suspected than determined, are probably causes of these dif- 
ferences. The same is true of the form of the fracture, simple, com- 
minuted, or transverse, and of obliquities of direction without rule or 
measure, quite as impossible to explain as to foresee. To sum up, 
we can establish the connection of falls with fractures, and form a 
general idea of their mechanism ; but the true theory, which would 
explain the essential details of the phenomenon, has hitherto escaped 
our search. 

Rude shocks, such as a blow with a stick or a stone, usually cause 
simple and direct fractures. I have several times broken all the 
long bones, in the dead subject, with a large iron lever; but have 
almost never caused comminuted fractures; moreover, and I shall 
have occasion to revert to this point before long, I have frequently 
produced only incomplete fractures. Nevertheless, I have seen in 
the living body bones comminuted by direct violence, when very 
great; it is thus that a mass of stone, or a beam, or some other 
heavy body, falling from a height, commonly breaks the bones into 
splinters ; and so also with bodies propelled by gunpowder, as a ball, 
a biscayen, a splinter from a howitzer, etc. Simple, or rather uncom- 
plicated fractures, are very rare ; almost always there are splinters, 
and fissures extending far from the point of injury. 

[A man, aet. about 50, was brought to the Pennsylvania Hospital, 
in the autumn of 1855, having sustained various severe injuries by 
the explosion of a blast ; he died the next day, and in the examination 
of the body, a complete comminution of the head of the tibia was 
found, with merely a slight contusion externally. This could only 
have been caused by a blow from a fragment of rock.] 

Some blows, from the obliquity of their direction, or from the 
form of the bone, may on the contrary give rise to indirect fracture. 
Thus a blow on the outer face of the trochanter major produces 
direct fracture, or even crushing of the bone; a blow on its anterior 
face would rather cause an intra-capsular fracture of the cervix 
femoris, which would be obviously indirect. A violent blow on the 
sternum will sometimes produce a direct fracture of this bone, but it 
may break, indirectly, the ribs or their cartilages, etc. 

Pressure acts in the same way, directly or indirectly, but more 
slowly; so that the fracture is less sudden, and one may actually 
measure the interval between the rupture of the first and last of the 
longitudinal fibres. It is therefore thought that if during that interval 
the pressure should cease to act, the bone would be but partially broken. 
This in fact occurs quite often, especially in the ribs; and I have 
said that in the large bones of the extremities, powerful concussions 
may produce a similar effect. This theory, then, would indicate that 



A TREATISE ON FRACTURES. 37 

the rupture occurs by an excessive bending of the bone, and that the 
fibres on the convex side of the bone during such flexion undergo a 
severer strain, and should yield first. However, there are some ex- 
ceptions to this rule. M. Lisfranc has cited a case, to which I shall 
again refer, of fracture of the external table of the ribs, with flexion 
inward of the internal table ; and I have myself dissected, in an old 
man, a fracture of the same kind, in which the rib had been bent in- 
ward, the convex face resisting, and only the concave surface giving 
way. [See Fig. 10.) I made then upon the sound ribs of this sub- 
ject some experiments, several of which gave me the same result. 
I suppose that the fact, thus attested, will not be suffered to go un- 
explained ; but this task I willingly leave to any one who may choose 
to attempt it. 

Under the head of pressure belong bending forces applied to bones 
in their continuity, increasing or lessening their natural curvature, 
just as when a stick is bent over the knee. Only, in pressure, the 
bone is fixed at its two ends, and the force exerted on it acts in the 
interval; while in the flexion now alluded to the bone is fixed at 
some one point, and the force exerted on it at one or both ends. A 
young plasterer, driving his cart along a very muddy road, had put 
his foot in a deep rut ; at the same moment he tried to whip up his 
horses ; the blow missed ; he was dragged forward, nearly fell, and 
had his leg broken by the edge of the rut.* [Might not two forces 
be said to have acted in this instance on the ends and middle of the 
bone? The weight of the body would act above; the bottom of the 
rut would fix the foot, and the edge of the rut bear against the middle 
of the leg ; the 'latter would be in fact the agent producing the frac- 
ture.] In the reduction of old luxations backward of the elbow, 
more than once the forced flexion of the forearm has broken the 
olecranon, by the same mechanism. 

Torsion acts on the whole extent of a bone, and usually breaks it 
at its weakest part; it is therefore always an indirect cause. It some- 
times assists pressure ; thus strong pressure on the sternum fractures 
the ribs, both by curving and by twisting them. At other times torsion 
acts by itself; it is the sole cause of many fractures at the lower ex- 
tremity of the fibula. It may even act on the diaphyses, but there must 
in such case be either an immense force exerted, or some alteration 
of the osseous tissue. In this way it often is that patients affected 
with rachitis or cancer fracture their limbs by turning in bed. While 
trying to reduce a very old luxation of the femur, I charged an in- 
telligent assistant to rotate the thigh outward at a given moment. 
The bone resisted this movement, so that the rotation became a 
torsion, which, though gently made, fractured the femur at its lower 
third; but the severe and prolonged pains, which accompanied this 
fracture, would seem to indicate a previous alteration in the bone. 

* Journal Gtntral de Mtdecine, tome xxiv, p. 375. 



38 A TREATISE ON FRACTURES. 

Other fractures are due to violent traction, sometimes direct, as 
when a limb is drawn in by machinery; sometimes indirect, acting 
obliquely on the bone, as if to bend it ; thus the inner malleolus may 
be torn off by the eversion of the foot, or the fibula be broken by its 
inversion. Fractures of the patella by muscular action occur in 
both ways, but oftener by oblique than by direct traction. I have 
related, in my Anatomie Chirurgicale, the experiments of Troja and 
of Wilson, to determine the force with which the bones resist direct 
traction ; thus the ulna of a young man of twenty, stripped of its peri- 
osteum, yielded to a force of 464 pounds ; that of the opposite side, 
retaining its periosteum, required a force of 485 pounds. To pull 
away an epiphysis, the periosteum being intact, 550 pounds were 
necessary; but 119 pounds sufficed when the periosteum was re- 
moved. These experiments, which call for repetition and variation, 
differ extremely from the results of mere calculation. To cite but 
one instance; supposing a stout porter, weighing 180 pounds, to carry 
on his back a load of 1900 pounds, Borelli has estimated the trac- 
tion sustained by the patellae as at least 24,960 pounds, which ex- 
ceeds all probability. I shall content myself with this significant 
comparison of the results of mere theory and those of experiment. 

Muscular action, it would at first seem, could only act by traction 
on the extremities of a bone, as in the fractures of the patella, 
already cited. But sometimes this traction acts on the continuity 
of the bone, the two extremities remaining fixed ; and thus are ex- 
plained certain fractures of the long bones ; again, muscular force 
may act by confining the middle of a bone, while its extremity is 
raised by a violent motion ; thus we see the humerus broken by an 
effort to plant a blow, to throw a stone, etc. The bones oftenest 
fractured by the action of the muscles, are the patella, calcaneum, 
olecranon, humerus, and femur; some analogous instances are re- 
lated of fractures of the sternum, ribs, clavicle, forearm, and even of 
the tibia. From what I have seen, it appears to me that there must 
be either some previous alteration of the osseous tissue, weakening the 
resistance of the bone, or an abnormal increase of muscular power, 
as in convulsions and epilepsy; I shall take care to recur to these 
facts elsewhere, at the proper time and place. 

Finally, violent explosions of gas, the sudden disengagement of a 
mass of vapor, may become causes of fracture, whose efficiency can- 
not be doubted. Two soldiers had the ends of their thumbs applied 
over the touch-hole of a cannon; as they rammed down the cart- 
ridge, the piece went off unexpectedly; the explosion at the touch- 
hole was very violent, and one of them had both phalanges of the 
thumb fractured.* We have even seen, in the terrible catastrophe 
on the Versailles Railroad, the skull broken all round and splintered 

* Ravaton, la Ckirurgie d'Armde, p. 309. 



A TREATISE ON FRACTURES. 39 

by the vapor formed in the boiling of the brain; a fearful instance of 
the power of the agents put in operation by human hands, but which, 
in such a degree, offers to art only the interest of a sad curiosity. 

Such is a nearly complete list of the causes of fractures in the 
ordinary course of life; but there remains a question much more 
difficult to approach, viz., how are fractures caused in the foetus, or 
in intra-uterine life? 

We must at the outset exclude fractures caused in the process of 
labor, whether by the head pressing into a narrow pelvis, when the 
skull is exclusively involved, or by the operations of the accoucheur, 
which act especially on the humerus or femur.* Limiting ourselves, 
then, to such as occur during pregnancy, there are first those due to 
direct concussions acting through the abdominal and uterine parietes 
of the mother. 

Devergie has given the history of a woman, who, when seven 
months gone with child, struck her abdomen severely against the 
corner of a table. The pain was excessive, and lasted some time. 
This woman was brought to bed, at the usual time, of a pretty stout 
child, which had a large tumor in the region of the left clavicle. 
The child died on the eighth day, and the autopsy showed the tumor 
to be formed of a solid and voluminous callus, reuniting a fracture 
of the clavicle; the fragments had somewhat overlapped each other, f 
The specimen was placed in the museum at Val-de-Grace, but has 
unfortunately been lost. 

Could a similar cause produce a fracture with projecting frag- 
ments ? The following fact seems decisive on this point ; although I 
would rather explain it by muscular contraction subsequent to the 
fracture. A young woman, six months gone, had a fall, striking 
upon the lower belly; she immediately felt the child move forcibly, 
but it soon became quiet. She gave birth at term to a very weak 
and meagre child, having in one leg a transverse wound with pale 
and flaccid edges ; through this wound projected the diaphysis of the 
tibia, entirely separated from its inferior epiphysis. The projecting 
bone was necrosed; Carus in vain attempted its reduction, and gan- 
grene destroyed the child's life on the thirteenth day.J 

A more extraordinary case is that of a compound fracture without 
external violence. A pregnant woman heard, during a movement of 
the foetus, a sound like breaking a stick ; and from that time she felt 
in her belly pains as if something was pricking her. Six weeks 
after, she gave birth prematurely to male twins, one of which had a 
fracture of the left femur ; the bone projected from the integuments 
more than an inch, and was carious. This fact, which is accredited 
to Strambio, has received more than one interpretation. Some have 

* Chaussier, Discours pron. a la distrib. desprtx de la Maternity, 1810. 

t Revue Mtdtcale, 1825, tome ii, p. 152. 

% Archives Gen. de Me'decine, tome xvi, p. 288. 



40 A TREATISE ON FRACTURES. 

seen in it a fracture by muscular action; others, considering the 
presence of the other foetus, have presumed that the wounded one 
had entangled his thigh with his brother's limbs, and broke it in 
withdrawing it ; and Oswald has jumped to the conclusion that such 
a fracture could not occur but in a double pregnancy.* It is at 
least prudent to wait for additional facts. 

If then so much obscurity involves the etiology of simple frac- 
tures, the difficulty is much greater in those singular cases where 
very numerous fractures exist in almost all the bones of the skeleton. 
Malebranche says that there was seen at the Invalides, about 1668, 
a young man, born an idiot, whose bones were all broken at the 
points where those of criminals are broken; he refers the cause to 
the mother's imagination, she having wished, while pregnant with 
him, to see an execution upon the wheel. Hartzoeker, in 1708, re- 
lates a similar case, and Muys, in 1751, a third; but neither of them 
had seen the subjects. A fourth instance was observed by Amand; 
a lady of quality had an abortion; the foetus, still-born and ap- 
parently at the fourth or fifth month, presented at the middle of 
the forearms, thighs, and legs, impressions exactly resembling those 
made by the iron bar on the limbs of a person suffering on the 
wheel; the bones were distinctly divided at these points, and held 
together merely by the skin. The accoucheur in this case dared not 
address any questions to his noble patient.f 

Monteggia saw also, in a new-born child, twelve fractures still un- 
united, at the middle of the long bones of the four extremities ; the 
mother had had three severe falls in the course of her pregnancy, a 
circumstance which would seem to suggest a more plausible etiology ; 
but this experienced observer, struck by the number and symmetry 
of the fractures, suspected some original defect in the formation of 
the bones. 

But Chaussier has published two cases in which the causes seem 
entirely beyond detection. The first, and the less complete, was 
that of a new-born child, left at the Maternity ; the mother, so far 
as known, had met with no accident during her pregnancy, her ac- 
couchement had been easy, and no violence had been done to the 
child. It died a short time after, and the autopsy revealed at least 
forty-three distinct fractures; some of these were recent, and others 
more or less united. 

The second case was recorded in 1813. A healthy woman, mother 
of four healthy children, had a fifth pregnancy, and came to her full 
term without accident; but she remarked that the movements of the 
foetus had been rare and slight. The accouchement was easily ac- 
complished in three hours ; the child died in twenty-four hours with 

* See art. Fracture in the Diet, dies Dictionnaires, and Archives de M4de- 
cine, tome xvi, p. 444. 

f P. Amand, Observations sur les Accouchements, obs. 8. 



A TREATISE ON FRACTURES. 41 

very marked cyanosis ; the lungs were very small ; the skull, on the 
contrary, was very large, and contained a great quantity of liquid. 
But the osseous system displayed the most remarkable lesions. There 
were counted in it not less than one hundred and twelve fractures, 
to wit : seventy in the ribs, twenty in the superior extremities, and 
twenty-two in the inferior. The clavicles, the scapulae, all the large 
bones, the fifth metacarpal bone of each hand, and the second meta- 
tarsal of the right foot, showed traces of fractures, some yet movable 
and crepitating, others already consolidated. The long bones of the 
extremities were evidently shorter, but thicker, than usual, with dif- 
ferent degrees of curvature; their periosteum was white and thick, 
especially at the points recently fractured ; the surfaces of these frac- 
tures were red, uneven, rugged, and interspersed with little grains 
and laminated filaments going from one surface to the other. The 
muscles of the members were thick, folded, and sinuous in the direc- 
tion of their length.* 

To what cause should such lesions be attributed? The old hypo- 
thesis, that they are due to the mother's imagination, cannot sustain 
itself before modern facts ; neither could the premature evacuation of 
the bag of waters, nor the contractions of the uterus on the foetus, 
produce such results; and the symmetry of the fractures, which 
struck Monteggia, is not met with in other observations. Chaussier 
ascribes them to an internal disposition, an alteration of nutrition 
analogous to that which renders so frail the bones of old men and 
some adults, offering as proof the general fragility of the bones, their 
red color, more marked than normal, and the development of their 
blood-vessels. This would resemble commencing rachitis ; and the 
equally numerous fractures, seen sometimes in rachitic infants, give 
some weight to this conjecture. Finally, some have alleged the 
contractions of the foetal muscles; and in Chaussier's last case, the 
hydrocephalus may have given rise to convulsions. It is probable 
that there may be at the same time alteration of the bones and con- 
tractions of the muscles, but this needs clearer demonstration. 

* Chaussier, Mimoire sur les Fractures et les Luxations survenues & des 
Foetus, etc. ; Bulletin de la Faculty de MCdecine de Parts, 1813, p. 301. 



42 



A TREATISE ON FRACTURES. 



ARTICLE II. 



VARIETIES OF FRACTURES. 



All fractures may be arranged under the following four heads : 
(1) incomplete; (2) complete, but simple; (3) multiple; (4) com- 
plicated. 

[It will be seen that this division does not agree with that drawn 
by American or English surgeons, which, in order to contrast it with 
this, I will state as follows : — 



Simple 



(In long bones,) 
Transverse, 
Oblique, or 
Longitudinal ; 



All fractures are 
or 
either of which may be 
Complete or incomplete ; 



Compound; 



(In flat bones,) 
Fissured, 
Stellate, or 
Camerated ; 



(In either,) 

Comminuted, } , ,, 

Complicated,} or both 5 

(In the bones of the skull,) 

Depressed. 

The main difference, after all, will be seen to lie in the different signi- 
fication given to the words simple and complicated, which the French 
use as equivalent to our words single and compound. Multiple 
fractures are not with us considered as a distinct class.] 



§ I. — Of Incomplete Fractures. 

By incomplete fractures are meant such as involve only a portion 
of the thickness of a bone ; they are distinguished into two very dif- 
ferent species, viz., fissures, and incomplete fractures, properly so 
called; to these I would add splintered fractures, and perforations. 

(1.) Of Fissures. — The subject of fissures or cracks having given 
rise to much discussion among surgeons, I shall treat it at some 
length, and shall examine it in regard successively to the flat, thick, 
and long bones. 

Among the flat bones, those of the cranium are particularly sub- 
ject to fissures. They were recognized and described in the time of 
Hippocrates, and it would be superfluous to quote examples of them. 
They are not so common elsewhere ; but I am not sure that this 
rarity is not owing to the negligence of pathological anatomists. 
For myself, I have seen them, more than once, in the fossa infra- 
spinata of the scapula, but always in dried specimens, in which it was 



A TREATISE ON FRACTURES. 43 

not certain that they had occurred during life. Still, we have other 
observations showing their existence in the lower maxillary bone, in 
the ribs, and in the ossa ilii. 

A young man, sixteen or eighteen years old, fell from a second story, 
and died instantly. Among other injuries, M. Gariel discovered at the 
autopsy, (1) in the lower maxillary bone, at the level of the entrance 
of the dental canal, on the left side, a complete fracture posteriorly, 
while anteriorly, beneath the masseter muscle, there was no trace of 
any solution of continuity: (2) in the left ilium, near its junction 
with the sacrum, a fracture complete posteriorly, but incomplete on 
the anterior and inner face of the bone.* 

I have before me an os innominatum, which has in its iliac fossa a 
fissure limited to the internal table of the bone; and another, tra- 
versed in its whole thickness by a wide fissure, which descends from 
the iliac crest across the sacro-iliac facette, to about one-third of an 
inch from the sciatic notch. These two bones certainly belonged to 
adults ; unfortunately I have not then previous history. Gulliver says 
he has seen an incomplete fracture of the pelvis, in a child run over 
by a carriage-wheel; it was probably a simple fissure.f Lastly, the 
following clear instance of fissure of a rib was observed by M. Lis- 
franc. 

A young girl, aged 15, was thrown down by a cabriolet, the wheel 
of which passed obliquely over the right side of the thorax ; she died 
the next day. The autopsy disclosed, besides various other lesions, a 
fracture at about the middle of the first rib on the right side, involv- 
ing its whole thickness ; in the second rib an incomplete fracture 
involving both the anterior and posterior faces of the bone; in the 
third, a longitudinal fracture between one and two inches in length, 
occupying the lower edge of the bone; the fourth and fifth had sus- 
tained fracture of their external tables, with considerable flexion, 
while in the sixth the external table was broken, and the internal 
one merely bent. % 

Among the thick bones, fissures are infinitely more rare. Gul- 
liver says that there is, in the Museum of the College of Surgeons 
at Edinburgh, a patella having a transverse fissure on its articular 
face, without any corresponding mark anteriorly. I have, and have 
had drawn, [see Fig. 79,) a specimen of the same kind; but a careful 
examination showed me on the external face a transverse depression, 
seemiDg to indicate a complete fracture without notable displace- 
ment. Perhaps the same is true of the patella at Edinburgh. I 
have also seen, in a specimen sent me by M. Voillemier, the head of 
the humerus traversed by two or three pretty deep fissures, without 

* Bulletins de la Sociiti Anat., 1835, p. 24. 

t Gazette Medicate, 1835, p. 472. 

% Nouvelle Biblioth. Midicale, July, 1828, p. 42. . 



44 A TREATISE ON FRACTURES. 

any external separation. (See Fig. 23.) Lastly, Palletta has given 
an account of a fissure observed in a vertebra, which will be of some 
interest here. 

A man, aged 35, was pulling with all his strength at a rope, to 
bring down a tree ; suddenly he lost his equilibrium, and fell down 
with violence; by the shock, the whole lower half of his body was 
paralyzed, and on the eleventh day he died. At the autopsy blood 
was found in the pleurae, as well as among the muscles of the back. 
Raising up the anterior vertebral ligament in the thorax, the third 
dorsal vertebra was seen to be cracked from above downward, with 
detachment of part of the external layer of its body. Opposite the 
fissure, the medulla spinalis was narrowed as if compressed by a 
band, and its membranous sheath seemed empty and flaccid. It 
would seem, from this account, that the fissure was limited to the 
body of the vertebra; I regret, however, that Palletta has not ex- 
pressed himself more precisely.* 

There remain yet fissures of the long bones, or rather of the dia- 
physes; and it is on this point that the discussion has been most 
active. Felix Wurtz has devoted to them one chapter of his book, 
but without citing any instances. In 1686, Stalpart Vanderwiel 
published, under the title of Fissure of the Tibia, an account of a 
servant wounded in the leg by the kick of a horse. The wound 
cicatrized, but the pain continued; a surgeon, suspecting fissure, 
trepanned the tibia, and the patient recovered. As it is not stated 
whether or not the diagnosis was confirmed, there is still room for 
doubt in regard to it. 

J. L. Petit, not troubling himself with antecedent facts, denied 
the possibility of fissures of the long bones, because, said he, a blow 
sufficient to fracture the bone in its length, would break it across 
much more readily. Duverney, however, collected several new in- 
stances, which, being opposed to the opinions of the school, were 
rejected with great disdain. I shall not stop to examine the strange 
criticisms passed upon them by Louis ; but they amount to this pe- 
remptory argument, that in neither instance did fissure exist, because 
fissure was impossible. f Not only is fissure of the long bones very 
possible, but we have examples enough of it to study it in a satis- 
factory manner. 

In the first place, it has already been observed in most of the 
bones of the extremities; but most frequently in the lower limbs, 
and in the tibia oftener than in the femur. There are two fissures 
of the tibia in the Muse'e Dupuytren; one without any history (No. 
699;) the other, (No. 221,) presented by MM. Marjolin and Rullier, 

* Palletta, Exercitationes Patholog., Mediolani, 1820, p. 236. 
t Louis, Discours Prtliminaire du Trait6 des Maladies des Os, de J. L. 
Petit, 1758, p. 105, et seq. 



A TREATISE ON FRACTURES. 45 

was struck by a ball, the impression of which may be seen on its 
inner margin. To these may be added Duverney's two cases, and 
three others, due to Be'cane, LeVeiHe* and M. Campaignac. 

As to the femur, M. J. Cloquet has figured a case, complicated 
indeed with a perforation of the bone. A Russian soldier, in 1814, 
had the femur traversed by a ball from before backward, above the 
condyles; he died of hospital gangrene; at the autopsy there was 
found, besides the clean-cut perforation made by the ball, a fissure 
separating the two condyles, and passing up nearly to the middle of 
the bone.* But the finest possible example of pure unmixed fissure, 
is doubtless the one I have had drawn from a specimen given by Fleury 
to the Museum at Val-de-Grace. (Fig. 1.) 

In the upper extremity, I know of but one case in the humerus, 
and another in the ulna. The former is reported by Campaignac, to 
whom it was communicated by M. Ripault. A boy, eleven or twelve 
years old, had the forearm drawn in by the wheel of a machine, the 
arm being also so mashed as to require the immediate performance 
of disarticulation of the shoulder. The humerus was found split 
lengthwise, and the fissure, directed from without inward, involved 
the entire thickness of the bone; it began toward the inferior ex- 
tremity, above the tuberosities, and ended at the insertion of the 
deltoid ; its edges were separated, especially below, so that the blade 
of a knife could be passed in between them. 

The other example, cited by Chaussier in his lectures, occurred in 
a criminal, forty years old, who died a few hours after being tortured ; 
the autopsy revealed, in the upper fourth of the ulna, a linear frac- 
ture directed obliquely toward the articulating extremity, and limited 
to the middle of the thickness of the bone.f 

We see that all these cases concern subjects between twelve and 
forty years of age, that is to say, from adolescence to adult age. The 
causes are exactly the same as those of other fractures; violent shocks, 
gun-shot wounds, whether the ball lodges in or traverses the bone; 
strong pressure; in one case reported by M. Campaignac, a simple 
fissure was caused by a fall. A woman, aged 38, threw herself from 
a second-story window, and died instantly. The left tibia presented 
in its superior third four longitudinal cracks, one anterior, with an 
oblique and tortuous course, extending from the middle of the in- 
ternal articular cavity as far as the upper edge of the external face 
of the bone, four and one-third inches below the joint; another 
situated on the inner face, and two posterior, nearly vertical, paral- 
lel to one another, distant from the other about one inch, not reach- 
ing up to the articular surface; these three cracks were each about 

* J. Cloquet, These du Concours de Pathol. Externe, 1831, pi. xii, fig. 7. 
f Chaussier, Mtdecine Legale, p. 447, et seq. 



46 A TREATISE ON FRACTURES. 

two inches and two-thirds long, and showed no separation; but the 
anterior one gaped slightly, especially above.* 

These fissures are rarely single ; generally there are several, of 
various extent and depth. The smaller do not reach the medullary 
canal ; I convinced myself of this by examining the specimen at Val- 
de-Grace; the larger occupy the whole thickness of the wall, but do 
not leave a notable separation between their edges. If, on the con- 
trary, they traverse the whole thickness of the bone, which only 
occurs when they reach one of its edges or extremities, then there 
may be a separation of one-thirtieth to one-fifteenth of an inch, as in 
the cases of MM. Ripault and J. Cloquet. 

It will be seen that even with this separation, it is nearly impossi- 
ble at once to diagnose a fissure, unless an external wound exposes 
it to view. It is, therefore, only from its consecutive phenomena 
that one can suspect its existence ; but the gravity of the injury then 
calls for all the attention of the surgeon. 

It is to be regretted here, that surgeons have not left us more 
complete observations; we see, indeed, that fissures have always in- 
volved death, or at least such danger as could only be avoided by an 
operation; but the nature of the accidents has not been sufficiently 
explained. Tta patients of Becane, of Leveille*, of M. J. Cloquet, 
died. Duverney speaks likewise of a surgeon of Paris, who fell a 
victim to a fissure of the tibia, recognized too late; and the speci- 
mens in our museums, the histories of which we do not know, indi- 
cate by the recent state of the fissures that the limbs were soon lost. 
At least the known facts show very clearly how cautious must be 
the prognosis, whenever fissures are suspected, however slight the 
injury may at first seem. Be'cane's patient had received a blow with 
a hammer on the middle of the tibia, which did not hinder his walk- 
ing afterwards; but he met with several other accidents, and finally 
died, when the tibia was found split for a length of about three and 
a half inches, f Le'veille"s case is still more striking. An Austrian 
soldier had received, at Marengo, a ball in the inferior third of the 
leg. He nevertheless went on foot several miles, to Alexandria, 
whence he was carried to Pavia. The wound seemed simple enough, 
and only to require the exfoliation of the portion of bone touched by 
the ball, in order to cicatrize. This did not occur, and amputation 
of the thigh became necessary. Dissection showed in the tibia, be- 
ginning from the impression of the ball, several longitudinal and 
oblique lines, which reached from the lower third to the femoral ex- 
tremity of the bone ; they were fissures involving the whole thick- 
ness of the bony wall, into the medullary canal. 

* Campaignac, Des Fractures Incompletes, etc.; Journal Hebdomadaire, 
1829, tome iv, p. 115. 

f Becane, Abre'ge' des Maladies qui attaquent la Substance des Os; Toulouse, 
1775, p. 134. 



A TREATISE ON FRACTURES. 47 

Duverney's observations, the most complete yet possessed by sci- 
ence, will not be out of place here. 

A canon fell from a height, striking the middle of his left leg; 
great pain, ecchymosis, and swelling ensued; bleeding and topical 
remedies allayed these symptoms in a few days; he thought himself 
well, and acted accordingly. "When going to bed, he perceived a 
redness on the anterior part of this leg, and some tension also. In 
the course of the night he was attacked by pain, so excessive that he 
could not bear it. It was determined to make an incision down to 
the bone, at the most elevated point of the swelling ; from this issued 
a sanguinolent serosity, apparently from between the periosteum and 
the bone, the former being detached for more than two fingers'-breadths. 
It was easy to see whence these symptoms arose, since there appeared 
a very extensive longitudinal fracture ; the incision had to be en- 
larged each way; and the patient was much relieved. To hasten 
the cure, and avoid the accidents to be feared in cases of this sort, 
recourse was had to the perforating trephine and exfoliator, with suc- 
cess, as the fissure did not penetrate to the medullary canal. The 
patient was cured in less than two months." 

Here the crack was slight, and merely caused a stripping off of 
the periosteum, perhaps with some superficial alteration of the bone. 
In the second case, the fissure reached the medulla, causing it to 
suppurate. 

A garde-du-corps received a kick from a horse, on the middle of 
his left leg. The very acute pain he felt at the moment was gradu- 
ally succeeded by a numbness so great that he could not move the 
leg. Topical applications were made ; the skin became gangrenous ; 
nevertheless, the wound soon healed. Three months afterwards, there 
suddenly came on a pricking pain, which prevented his attending to 
his duty. After trying various remedies, it was resolved to lay bare 
the bone. "The incision being made, the bone appeared of a brown 
color, somewhat raised, and with a very evident fissure, quite long 
and deep." The wound was enlarged upward and downward; dry 
dressings were applied, and the next day the superfluous bone was 
removed with the gouge and mallet. Pains recurring in the shaft of 
the tibia called for the reapplication of these instruments; at the last 
few blows there issued from the fissure a yellowish and very putrid 
liquid; and the pain was at once allayed. At the following dressing 
three crowns of the trephine were applied, and the disks of bone 
extracted ; the medulla was found to have suppurated. Four months 
sufficed for a complete cure. 

From all this we see that the symptoms are no other than those 
of contusion of the bone, so well studied by Ravaton, and that they 
depend sometimes upon periostitis, sometimes upon suppuration in 
the medullary canal; which explains at once their slow development, 
and their gravity, yielding only to trephining of the bone. The 



48 A TREATISE ON FRACTURES. 

fissure itself is but a slight affair, and it is presumable that more 
prolonged rest, and a more persevering use of antiphlogistics, would 
avert all danger. Probably more than once fissures have even been 
thus cured without being recognised; and this consideration is to be 
added to those which should awaken the attention of practitioners to 
this subject. 

(2.) Of Incomplete Fractures, properly so called. — I give this 
name to such fractures as, involving a part of the thickness of the 
bone, are accompanied by more or less flexion of the portion still 
resisting; this has been called depression in the flat bones, curvature 
or traumatic flexion in the long. 

The actual existence of these fractures has been denied, for various 
reasons. Some would regard the bending of bones without break- 
ing, as impossible ; others, on the contrary, assert that there may be 
simple curvature, and no fracture at all; the question is still under 
debate. 

Thus, as regards the flat bones, the surgeons of the last century ad- 
mitted depressions of the cranial bones, and of the ribs, without frac- 
ture. That the yet soft bones of a new-born child can be thus de- 
pressed, I know from my own experiments ; but I never have been 
able to cause permanent depression, except by breaking the bone at 
several points. Sandifort has figured in his Museum the two cases 
most applicable, at first sight, to the support of the doctrine of simple 
depression in the cranial bones. There is represented, first, the skull 
of an infant, whose head, a very large one, was tightly wedged in a 
cuneiform pelvis. Soek, an expert accoucheur, succeeded in saving 
both mother and child ; but the latter had sustained a great depres- 
sion of the skull, which resisted all remedial means, and it died at 
the end of four weeks. This depression involved the right parietal 
bone, extending from the lambdoid suture as far and even farther 
than the centre of the bone, a distance of two inches (fifty-four mil- 
limetres ;) its depth was the same, and it was limited below and in 
front by a rounded border. But at the bottom of the depression, 
and especially at the anterior portion of the bone, was a fracture an 
inch and one-third (four centimetres) long, reaching to the fontanelle, 
and already filled with reddish bony matter. 

Another child, likewise delivered by Soek, and this time still-born, 
showed a similar depression of the right parietal bone, and of the 
neighboring portion of the frontal. This depression was fourteen 
lines (thirty-one millimetres) in depth; but two fissures were seen 
near the coronal suture, one in front, already united, and one further 
back, closed by a membrane.* 

These depressions are by no means rare in the ribs, even in old 
men. There is shown (Fig. 10) a depression in the sixth rib from a 

* See SandiforVs Museum, tab. xxxiv, figs. 1 to 5. 



A TREATISE ON FRACTURES. 49 

fracture limited to the external table; much oftener it is the internal 
table which breaks, and there is generally at some other point 
another fracture, complete or incomplete. I shall refer elsewhere to 
this important variety of fractures of the ribs. 

As to the other flat bones, I can cite but one example of incom- 
plete fracture with depression, which occurred in the scapula. A 
laborer was working in an excavation, with his back bent, when a mass 
of building-stone weighing ten kilogrammes [something over twenty 
pounds avoirdupois] fell a distance of about fifteen feet, striking upon 
his left scapula. He was knocked down by the blow, but got up ; the 
pain caused by moving the arm preventing him from resuming 
his work, he came to consult me. The skin was severely contused 
toward the centre of the scapula; pressure on this point gave 
pain, and the finger sunk into a very marked depression, limited 
internally by a sharp osseous ridge, and externally rising gradually 
to the level of the rest of the bone. The scapula moved en masse, 
without any crepitus. I judged, therefore, that there was an incom- 
plete fracture, with depression, in the fossa infra-spinata. It was 
impossible to replace the depressed portion, and I contented myself 
with binding the arm to the chest by a bandage, till the pain should 
cease. 

In all cases, in fact, when a depression of this kind is merely 
painful, the simple indication is to assuage the pain by rest, and by 
antiphlogistics if necessary ; and this is true of fracture of the skull 
and of the ribs, as well as of those of the scapula. If the depressed 
fragments should cause graver symptoms, as for instance if they should 
penetrate the viscera, it would become necessary to elevate them. 
Hence, one indication for trephining in wounds of the head; and I 
shall speak elsewhere of the means of relieving depression of frac- 
tured ribs, generally without any operation. 

I do not know that similar fractures have been observed in the 
thick bones, although I would by no means pretend to deny their 
possibility. There has indeed been diagnosed an incomplete fracture 
in the cervix femoris, the structure of which much resembles that of 
the thick bones. Adams, in 1834, read to the Surgical Society of 
Ireland a paper on this subject; but I apprehend he mistook extra- 
capsular fractures, with impaction, for partial fractures.* The fol- 
lowing observation, published by M. Tournel, seems to me to be of 
more value. 

An old man of eighty-five, thrown down by a drunken comrade, fell 
on his buttocks, and could not rise; he was taken to the hospital. No 
shortening or crepitus was detected; but he complained of very 
acute pain, increased by the least movement, in the upper part of 
the thigh ; he could not raise the whole limb at once, and the soft 

* Gazette Mtdzcale, 1835, p. 641. 
4 



50 A TREATISE ON FRACTURES. 

parts about the hip-joint were considerably swollen. An intracap- 
sular fracture, without displacement, was suspected, and the long 
splint of Desault was applied. On the twenty-eighth day, the limb 
being of its normal length, and the pain being gone, M. Tournel 
thought the case had been one of mere contusion ; he therefore ceased 
making permanent extension. But, fifteen days later, the shortening 
reappeared, the foot was everted, the thigh slightly arched upward; 
the limb was placed on a double inclined plane ; the patient was, 
however, soon after seized with diarrhoea, and died three and a half 
months after his fall. The autopsy disclosed an incomplete fracture 
between the base of the neck and of the trochanter major, consti- 
tuting a long fissure, which from the digital fossa, internal to this 
trochanter, descended before and behind to a little below the tro- 
chanter minor; the latter being attached to the inner fragment. It 
was, therefore, intra-capsular above, extra-capsular below. Below 
the trochanter minor was a sort of osseous bridge, which had resisted 
the fracture. The surfaces were not immediately in contact, but 
joined at the upper part by a reddish bony matter interposed be- 
tween them, solid enough to hold the two fragments together.* 

There remain to be examined incomplete fractures of the dia- 
physes, which are not much better known than the others. Since 
1673, dissection has placed the fact of their occurrence beyond 
doubt. A child, twelve years old, in jumping, felt a pain in his thigh. 
He could, for two days, walk and go down stairs, putting the point 
of the foot to the ground; after which there ensued an acute inflam- 
mation, and a copious suppuration, which carried him off. Glaser 
made the autopsy, and among other injuries found a fissure extend- 
ing both longitudinally and transversely .f 

This observation remained isolated for nearly a century, and in- 
complete fractures were still regarded as impossible, when, in 1765, 
Camper, writing to the Edinburgh Society, asserted that they were 
not rare, giving a representation of a tibia affected with such a frac- 
ture, easily to be recognised in spite of consolidation. The fracture was 
on the anterior surface, near the middle of the bone; it had left a 
linear impression in the form of a finger-nail or a scale, so that 
Camper gave it the name "squamous fracture. "{ The tibia had pre- 
served its normal straightness ; and it would not appear that in 
Glaser's case the femur had undergone any shortening. But, lastly, 
A. Bonn published a third case in which the bone remained curved; 
it was the femur of a robust adult man, curved backward by ex- 
ternal violence; the posterior face still presented the marks of the 



* Archives de Mtdecine, 1837, tome xiv, p. 77. 
f Th. Boneti, Sepulchretum, Lugd. 1700, tome hi, p. 424. 
t Essays and Obs., Physical and Literary, of the Edinburgh Society, vol. 
iii, 1771, p. 537. 



A TREATISE ON FRACTURES. 51 

fracture, such as thickening and inequalities; the anterior face had 
remained intact, and offered only a simple concavity, smooth and 
polished.* 

Thus, curiously enough, pathological anatomy has thrice decided 
the question, hut theory still resists ; and when finally observations 
were made on the living subject, it was deemed preferable to believe in 
simple curvatures of the bones than in incomplete fractures. They 
are thus designated in the Thesis of Thierry, the earliest analytical 
work on this subject which I know of; the author had seen the follow- 
ing two cases. 

A child of ten years, having fallen from a horse, felt an acute pain 
in the right forearm. Thierry being consulted, found the forearm in 
a state between pronation and supination, and presenting a marked 
concavity on its posterior face, an equal convexity existing in front, 
so that it represented the arc of a circle ; there was neither mobility nor 
crepitation : the first phalanges were extended, the rest flexed. The 
surgeon had strong extension made, while he compressed the pro- 
minence ; thus he restored the straight form of the arm ; he applied 
a simple bandage, and at the end of twelve days the child was cured 
without either deformity or swelling of the bones. The other obser- 
vation referred to a child, seven years old, who fell from some height 
upon the right forearm; the symptoms were similar, and the cure 
took place likewise in twelve days.f 

Thierry at the same time cites A. Dubois as having seen analogous 
cases ; nevertheless, these remarkable facts went unnoticed until, in 
1820, a medical journal called attention to the subject, by publish- 
ing an observation dating from the year 1771. It was as follows. 

A little girl five years old, being mounted on an ass, fell off on the 
gravel. The left forearm was found completely bent at its middle, 
but without crepitation. The surgeon pressed pretty firmly, and in 
different directions, on the prominence formed by the curvature of 
the forearm ; the child declared that it felt nothing piercing it, though 
otherwise the pain was considerable. Moderate extension restored 
the straightness of the bones, and from these facts Chevallier con- 
cluded that the case was one of a simple bending. 

Now at length the subject was taken up; and Jurine, of Geneva, 
addressed to the same journal a note, in which the question assumed 
an entirely new aspect.^ "Accidental bending of the bones of the 
forearm," wrote he, "is not very rare; in the course of forty years 
I have treated twenty cases of it, and have seen it occur twice 
at the same point in the same individual. It takes place more 
frequently in young persons than in those of riper age. According 
to my observations, the scrofulous are more liable to it than others, 

* A. Bonn. Descript, Thes. Ossium Morb. Hoviani, 1783, No. 185. 

f Pierre Thierry, Thene Inaug., Paris, an xiii, No. 349. 

+ Journal de Corvisart et Boyer, tome xx, pp. 278 and 499. 



52 A TREATISE ON FRACTURES. 

from their tendency to rachitis ; it is the result of a force acting in 
the longitudinal direction of the bones. Both bones yielding at 
once, and always in the outward direction, the arc described by their 
curvature has different degrees, according to the amount of the force ; 
but these degrees have certain limits. It is toward the inferior 
third of the forearm that the greatest bending takes place; I have 
never seen it exactly at the middle. . . . These curvatures are not 
followed by any troublesome symptoms, at least I have met with 
none." 

He has thus seen the humerus bent forward and a little inward, 
in a child seven years old ; and in another child of about the same age, 
he has seen the lower third of the leg bent, like the forearm, but to a 
less degree. 

But what is most remarkable in the observations of Jurine, is the 
difficulty of reduction. "The first time I was called upon to treat 
this accident," says he, "I made continued extension, pressing 
strongly on the angle of the bones, and by this means I diminished 
the curvature, without succeeding in entirely effacing it. The appa- 
ratus I applied was very simple ; it consisted of a splint three inches 
wide, placed along the concave face of the forearm, and maintained 
there by a bandage reaching from the fingers to the elbow. At the 
end of a month I had obtained, by means of this compression, a 
diminution in the arc of the curvature. I now left off the bandage, 
so as to give liberty to the muscles, not doubting that the forearm 
would always remain slightly curved, as it then was; but I was 
agreeably surprised by seeing it resume insensibly its natural 
appearance; which I could not but attribute to the effect of muscu- 
lar action, or rather to the reaction of the compressed bony fibres. 
After six months it was very difficult, and at the end of a year 
impossible, to say which had been the affected forearm." 

" All the patients treated by me for this injury have been simi- 
larly affected, and the result has been nearly the same; in a single 
case in which the curvature was less, I used merely the splint and 
bandage, and the cure took place equally well." 

The assertion of Jurine concerning the frequency of these fractures 
is somewhat surprising, when we consider the silence of most authors in 
regard to them, and the small number of cases published. Mr. Hart 
says that he has seen five cases within the space of three years; and 
Johnson adds that he has himself met with eight others ; but the other 
observers who have spoken of it, MM. Champion, Wilson, Pourche', 
Campaignac, J. Cloquet, and Gulliver, have seen this lesion but once; 
it is recorded but once on the registers of the Hotel-Dieu for the 
eleven years examined by me ; and, lastly, I have myself seen but 
one example.* 

* See for these several cases, Hart, Partial Fracture of the Long Bones in 
Children, Medico- Chirurg. Review, April, 1832, p. 588; Champion, Observa- 



A TREATISE ON FRACTURES. 53 

But, on the other hand, the facility of its production in the dead 
subject is to be thought of, and lends strong support to the assertion 
of Jurine. M. Campaignac succeeded, in 1826, in half breaking 
the tibia and fibula, by fixing the leg in a vice and forcibly bearing 
the foot outward. Its occurrence in this manner is rare ; for my 
own part, as I have already said, I have used a direct blow by means 
of a large iron bar, and have obtained partial fractures in all the 
long bones of the extremities, not only in young, but in old subjects. 
Some skeletons seem absolutely to resist fracture of this kind ; the 
bones of the forearm sustain it most readily ; the femur and tibia 
least so. But I have so often succeeded, that it has occurred to me 
to inquire how it is that these incomplete fractures are so rare in 
practice ; and whether they often pass undiagnosed, or, immediately 
after the blow, are made complete by muscular contraction or by a 
consecutive fall. Besides, these fractures, in a manner artificial, 
present all the phenomena observed in the living body — the bending 
at an angle, easy to overcome in some cases, but in others impossible, 
from the impaction of the serrations of the fractured portion. One 
can get a very good idea of this from Fig. 2. 

We see, then, that so far, whenever the state of the bones has 
been examined, whether after experiments or in autopsies, incom- 
plete fractures have always been found ; never simple curvatures. I 
am aware that something may likewise be said in support of the doc- 
trine of mere curvatures. It is very true that Dethleef, believing he 
had broken both bones in a dog's leg, found the fibula bent without 
fracture. Similar results were obtained by Duhamel in a lamb, and 
by Troja in a pigeon. I have twice succeeded, myself, in bending 
the fibula and breaking the tibia. The possibility of mere curvatures 
is then indisputable ; but it must be remarked that as yet they have 
only been obtained in young animals ; that they have only been per- 
manent by reason of fractures with displacement occurring in their 
vicinity ; and that they differ widely from the curvatures believed by 
some to have been seen in man, in which the bent bone remained so 
of itself, resisting reduction even as far as complete fracture. 

[See an excellent article by Dr. John Rhea Barton, published in 
the Philadelphia Medical Recorder, for 1821 ; this is stated by Dr. 
Norris (Am. edition of Fergusson's Practical Surgery) to be the first 
English essay on this subject. See, also, an article by Dr. F. H. 
Hamilton, of Buffalo, N. Y., published in the New York Journal of 
Medicine for Nov., 1857.] 

The nature of the lesion being thus placed beyond doubt, let us 
seek, by the aid of known facts, to trace more exactly its history. 

First, it is in the bones of the forearm that it most commonly 

tions. etc. in the Journal CompUmentaire, October, 1818, p. 325 ; Wilson, 
Lectures on the Bones and Joints, 1820, p. 199 ; Campaignac, loc. cit.; J. Olo- 
quet, These du Concours, 1831, pi. xii, fig. 11 ; Gulliver, Medical Gazette, 1835, 
p. 472. 



54 A TREATISE ON FRACTURES. 

occurs. Settiog apart the observations of Jurine, it has been seen 
by Chevallier, Thierry, Wilson, Otto, Gulliver, M. Champion, and 
myself, only in the forearm. Are both bones always involved? 
According to Gulliver, there is in the Museum of the Royal College, 
at Edinburgh, an incomplete fracture of the ulna. Hart says that he 
has twice seen it in the radius alone. The same may have been the 
case in my patient ; and I have assured myself, by experiments on 
the dead subject, that the bending backward of the radius marvel- 
ously resembles that of both bones. At the same time, when the 
angle nearly reaches 90°, the ulna generally participates in forming 
it ; and in a case of this kind, Wilson actually found, at the autopsy, 
that both bones were involved. 

Next to the forearm comes the thigh. To the two cases of Glaser 
and Bonn, already mentioned, may be added a fracture of the same 
kind in the femur of the rachitic skeleton, No. 516, in the Muse'e 
Dupuytren ; moreover, Hart claims to have twice seen it during life, 
and Johnson likewise twice. 

The leg has afforded nearly as many examples as the thigh. Jurine 
mentions one case ; Johnson says he has seen the tibia thus frac- 
tured ; and, besides the specimen figured by Camper, we have an- 
other case of an autopsy communicated by M. Pourche' to M. Cam- 
paignac, in which the lesion was likewise limited to the tibia. This 
makes four cases, to which may be properly added two incomplete 
fractures of the fibula, ascertained by an autopsy by MM. Cam- 
paignac and J. Cloquet. 

Lastly, Jurine and Hart each appear to have once observed in- 
complete fracture of the humerus, and Johnson twice that of the 
clavicle ; so that all the long bones seem to have furnished their con- 
tingents to this variety of fracture. 

Age has here a remarkable influence. It is in infancy that these 
fractures have been nearly always observed ; but not, as one would 
presume, in the earliest period. Of fourteen subjects whose ages 
are stated, I have found but one of ten months (Hart) and one of three 
years (Wilson.) All the rest are comprised between five and thirteen 
years. The cases of Camper, Bonn, and M. J. Cloquet, seem to have 
occurred in adults. Jurine plainly states that he has seen it in mature 
age, and my own experiments sufficiently prove its possibility at any 
period. Girls would seem to be no more liable to it than boys. 

The causes are the same as those of complete fractures. Some- 
times they are indirect, and it may be noted that the majority of in- 
complete fractures of the forearm were thus produced by falls on the 
hand, the wrist being bent either forward or backward. Sometimes 
they are direct ; resulting from a blow, or from strong pressure. It 
is remarkable that causes of this kind prevailed almost exclusively 
in incomplete fractures of the lower extremity. 



A TREATISE ON FRACTURES. 55 

The symptoms are very variable. Generally the bone is more or 
less curved, the angle being always salient on the side of the frac- 
ture ; and this curvature can be diminished by sufficient pressure, 
but rarely entirely overcome, from the irregular interlocking of the 
serrations of the fracture. In Gulliver's case, a month was required 
to restore the forearm to its natural form. It appears, however, 
that sometimes perfect reduction can be immediately performed, if, 
indeed, the cases admitting of this were really cases of incomplete 
fracture. Lastly, at other times the fracture occurs without separa- 
ration or curvature ; the only sign of it is then the bending of the 
bone under pressure with the finger at the point involved. Yet we see 
this same symptom attend complete fracture in the living subject, 
when simple and without displacement ; but here the error in diag- 
nosis would be unimportant. 

The treatment consists, first, in obtaining reduction. For this, 
extension is entirely useless ; the only rational means being mode- 
rate pressure on the salient point until it is caused to disappear. A 
bulky member, such as the leg or thigh, should be extended on a 
solid plane, and the pressure made with the palm of the hand or 
with the wrist ; in the forearm, especially in young patients, we may 
grasp one end of the bone in each hand, bearing on the angle with 
the joined thumbs, as if to bend it in the opposite direction. If the 
curvature do not entirely disappear, it is prudent to wait, applying 
a compressing apparatus ; but if it still persist after several days, it 
must be overcome at all risks, even, as has occurred to me, by ren- 
dering the fracture complete. If there be neither separation nor 
curvature, the diagnosis always remains very uncertain. In case of 
doubt, we should proceed, without any previous manipulation, to 
apply the apparatus. 

This should be very simple. When compression is required, one 
splint should be placed above, and one below ; both should be of the 
length of the bone involved, padded to protect the integuments, and 
retained by a roller. Reduction being once complete, a simple splint 
and roller are sufficient, or a starched or dextrinated bandage. 

The time necessary for consolidation is the same as for complete 
fractures. Thierry and Hart left off the apparatus at the end of 
twelve days. With young subjects, and in the forearm, such haste 
may give rise to no bad consequences; yet it seems to me to expose 
our patients to the double danger of a recurrence of the fracture, and 
of those pains often caused by imperfect formation of callus. 

In fractures of the lower extremities, to commit the weight of the 
body to bones half fractured and but half united, would be a far 
more dangerous imprudence ; and so much the more, as there is no 
harm in waiting a little longer. 

The following is the history of a case in which I adhered to this 
rule : — 



56 A TREATISE ON FRACTURES. 

A little girl of eight years, strong and well proportioned, was run- 
ning in one of the courts at Bicetre, when she was tripped up by some 
obstacle, and thrown against a door, her right hand forward, but 
flexed, so that its dorsal surface struck the door. She likewise lost 
her balance and fell on the ground, still on the same hand. Curi- 
ously enough, she felt no pain ; so that it could not be determined at 
which moment the bending had taken place. But when she rose up, 
the forearm was bent backward, at about the middle, nearly to a 
right angle. M. Verjus, my interne, was called at once, and, think- 
ing he had to deal with a fracture of both bones, attempted its reduc- 
tion. He brought the forearm to an angle of 160°, but no farther ; 
or, at least, when the pressure was removed which had given it its 
right form, it at once resumed this curvature. It must be added 
that, in commencing the reduction, there was perceived a slight cre- 
pitus ; but it could not be reproduced afterwards. I saw the patient 
the next morning. The angle remained at 160° ; there was neither 
mobility, projection of the fragments, nor crepitation; the forearm 
could even be pronated and supinated. No pain except on pressing 
at the highest point of the curvature. During three days things 
remained thus. Finally, on the fourth, the pain having disappeared, 
I tried to obtain complete reduction, and succeeded with the radius ; 
but I perceived at once a mobility at the level of the effaced angle, 
denoting positively a complete fracture. The ulna was as solid as 
before. I applied the ordinary apparatus, and the cure was com- 
plete by the twentieth day. 

(3.) Of Splintered Fractures. — I mean by splintered fracture the 
complete separation of a mere splinter, leaving the bone itself nearly 
solid. Fractures of this kind are usually caused by a cutting instru- 
ment, as by a blow with a sabre ; sometimes, also, a ball, grazing a 
bone, does not quite break it ; in either case, there must inevitably 
be the complication of an external wound. Instances of this kind 
are mainly seen in the skull, where they have been called, in Latin, 
dedolatio, in Greek, aposheparnismos. They are more rare in the 
bones of the trunk and extremities. Still, cases are given of ablation 
of larger or smaller portions of the facial bones, and of fractures of the 
extremities of the spinous apophyses of the vertebrae. M. Fauray- 
tier has shown me a femur in which a ball had carried off the base 
of the trochanter ; an exuberant callus had more than repaired the 
loss of substance which resulted without there being any other frac- 
ture, and a fibrous cord, extending from the orifice of entry of the 
ball to the bone, showed plainly enough the direction of the wound. 
M. Paillard mentions an officer who at the siege of Antwerp had 
part of the calcaneum carried away by a grapeshot.* Bavaton has 
given a case of a sabre-cut separating the lower extremity of the 

* Dupuytrcn, Traite des Blessures par Armes de Guerre, tome i, p. 338. 



A TREATISE ON FRACTURES. 57 

ulna. Other ablations of splinters, more or less important, have 
been observed in the elbow and knee, but we see that the spongy 
tissue is always concerned ; as to the compact portion, I know of but 
one case, also given by Ravaton, of a sabre-cut which, being inflicted 
on the middle and outer part of the right leg, carried off part of the 
spine of the tibia without injuring the rest of the diaphysis.* 

Could similar fractures be caused by external violence without any 
lesion of the integuments ? Undoubtedly, in some of the flat bones : 
it is not excessively rare to see a portion of the crista ilii detached 
by a severe blow. In fracturing the ribs in the dead subject, I once 
succeeded in scaling off the lower border of one rib, the rest of it 
remaining unbroken. But what would seem to surpass all belief, is 
that mere splinters have been detached from the middle of a dia- 
physis, as of the femur, by external violence which could not have 
produced a wound, reunion of the splinters having occurred. San- 
difort has had drawn two specimens of this kind, unhappily without 
knowing the history of the subjects ; but at sight of the plates 
there remains no doubt of the nature of the lesion he describes. 
One would call it the incomplete fracture of Camper, carried as far 
as total detachment of the splinters ; beyond this, laying aside all 
conjectures, I shall confine myself to translating literally the text of 
Sandifort. 

"No. 310. — Femur of the left side, in which is seen, projecting 
from the middle of the diaphysis, a splinter, an inch and a half 
broad, apparently detached from the external surface of the bone by 
violence from without, and but partially reunited to the diaphysis. 

"No. 311. — Femur of the left side, having, like the preceding, a 
splintered fracture at about the middle of its diaphysis. From its 
external face is separated a lamella, four inches long, which poste- 
riorly is reunited with the bone in nearly its whole length, but only 
to a slight extent in front. Above, it is fused with the bone ; below, 
it is separated for a length of two and a half inches, the interval 
amounting to three lines," [between one-quarter and one-third of an 
inch.] 

The treatment of a splintered fracture with a wound is very simple. 
If the splinter is small and unimportant, it hinders healing, and 
should be removed ; even if larger, it should be removed if its con- 
nections with the soft parts are too slight to afford hope of its reunion. 
In any other case, it should be replaced along with the soft parts, and 
an attempt made to obtain immediate consolidation. If, perchance, a 
simple splintered fracture is detected in the living subject, without 
any open wound, it will at most be only necessary to apply a roller 
to keep it in place ; but in the large bones of the extremities, rest is 
essential to complete consolidation. 

* Ravaton, La Cliirurgie d' Armie, pp. 619 and 630. 



58 A TREATISE ON FRACTURES. 

(4.) Of Perforations. — The name alone suffices to give an exact 
idea of these lesions ; it implies, strictly, that the bone is perforated 
through and through, or in one portion only of its thickness, by 
a foreign body ; whence it follows, first, that every perforation is 
attended by an external wound ; and, secondly, what is very im- 
portant, that the foreign body may or may not remain lodged in 
the bone. 

The agents producing perforations are penetrating instruments; 
swords, knives, lances, etc., or bodies propelled by gunpowder. 

Sword or lance wounds, penetrating the facial bones, are not rare ; 
I will here only recall the severe lance-wound which was received by 
the Due de Guise before Boulogne, and which earned him the name 
of Balafre* (gashed.) The bones of the skull are more resisting, and 
more liable to fractures with depression than to perforations from 
thrusts. Desport, however, relates the case of a journeyman tailor 
who had the right parietal bone pierced by a pointed bit of wood 
falling from a height ; it was necessary to trephine, to extract the 
foreign body, which, after penetrating as far as the brain, had broken 
off at the level of the bone. Percy, quoting this account, adds to it 
that of a servant at an inn, who had a large knife driven into the 
frontal bone by a drunken soldier. Ravaton also saw a slater killed 
by a blow with the point of his hammer, which had deeply penetrated 
the skull The vertebrse, though thick and spongy, have been more 
than once perforated in this manner; Percy reports the case of a 
grenadier wounded with a foil, the point of which was driven into 
the body of the fourth dorsal vertebra. Two centuries before this, 
Fabricius Hildanus had extracted for a young man half the blade of 
a long knife, buried for two years between the bodies of his third 
and fourth lumbar vertebrae. Ravaton has seen a sword-wound 
penetrate the scapula, and the sternum; lastly, notwithstanding their 
narrowness, the ribs have sometimes sustained such perforations; 
Percy witnessed the extraction of a sword-point, broken off in a rib ; 
and every one knows the far more celebrated case of Ge'rard, pre- 
served in La F aye's notes upon Dionis ;* the blade of a knife having 
pierced the rib and penetrated an inch into the thorax, was broken 
off on a level with the outer surface of the rib; the adventurous 
surgeon divided the intercostal muscles, and introducing his finger 
armed with a thimble into the thorax, pushed out the broken bit of 
the blade by pressing on the point. Cases might also be cited of 
perforation, by pointed weapons, of the spongy bones of the foot 
and hand; but it can hardly be conceived to be possible in the 
diaphyses, and I know at present of but one instance, in which 

* [Cours oV Operations de Chirurgie. ParM. Dionis. Fourth ed., with remarks, 
etc. by G. de La Faye. Paris, 1740.] 



A TREATISE ON FRACTURES. 59 

Ravaton had occasion to extract a sword-point half an inch long, 
buried in the middle and outer part of the femur.* 

Perforations by balls and other projectiles are much more frequent, 
and more varied in character. I shall not dwell much upon complete 
perforations of the cranial bones, of the sternum, vertebrae, and 
pelvic bones ; it is very rare in such cases for the ball, in its subse- 
quent course, not to so injure more important organs as to either 
produce immediate death, or to give the surgeon more serious cause 
for concern than the mere lesion of the bone. But incomplete per- 
forations present varieties which it is interesting and important to 
study. 

Gockelius, as quoted by Percy, relates that a ball, striking the 
frontal bone, traversed the external table and flattened itself in the 
diploe, in such a manner that it could not be extracted without 
injuring the internal table. Desport saw other cases in which the 
perforation of the external table was accompanied by fracture, 
complete or incomplete, of the internal table; and Percy succeeded 
in producing these strange lesions in his experiments on the dead 
subject, Sometimes the ball traverses the anterior wall of the 
frontal sinus, and lodges in the cavity, without wounding the pos- 
terior wall; Schmucker and Collignon, according to Percy, saw cases 
of this kind. Larrey, at the siege of Saint Jean d'Acre, twice saw 
a ball fracture the external wall of the sinus and then split in two, 
one fragment glancing over the forehead and the other lodging in 
the sinus. But Ravaton has reported an instance which deserves to 
be noticed more in detail : A grenadier had received a gunshot-wound 
between the eyebrows, and as the ball had not made its exit, the 
surgeon had at once judged the injury to be very severe. However, 
the probe, introduced into the sinus, not passing beyond it, he set to 
work searching for the ball, and finally, though not without difficulty, 
found it flattened and as it were incrusted in the floor of the sinus; 
he extracted it, along with several splinters, without needing to make 
any incision in the skin ; suppuration brought out afterwards other small 
splinters; but at the end of three months the patient, otherwise 
well, still had at this point a fistula discharging a slight whitish 
serosity. 

Incomplete perforations of the other bones of the trunk, and 
especially of spongy bones, like the vertebrae, present nearly the 
same varieties as those of the cranial bones, either a mere incrusta- 
tion of the ball at the surface, or a penetration of the projectile to a 
greater or less depth. The same is true also of the spongy portions 

* See for all the cases cited in this article. Eavaton, La Chirurgte d'Armte; 
Percy. Manuel du Chirurcfien d'Armte; Larrey, Clinique Chirurgicale, espe- 
cially tome v; Jobert, Plates d'Armes cifeu; Dupuytren, Trait6 des Blessures 
par Amies de Guerre, etc. 



60 A TREATISE ON FRACTURES. 

of the bones of the extremities, which, affording greater chances to 
art, claim more particularly the surgeon's attention. 

Lesions of this kind have been seen in nearly all the bones of the 
extremities, even in those which, from their small volume, would 
seem likely to escape. Thus M. Jobert mentions two patients, each 
struck about the middle of the clavicle, by a ball which lodged in 
the substance of the bone ; doubtless these two cases could only rank 
among the incrustations. But as regards true perforations, the head 
and neck of the femur have offered numerous examples; nearly 
all those who have described gunshot-wounds have had occasion to 
see them; and I have had represented (Fig. 3) a specimen of this 
kind taken from the Museum at Val-de-Grace. M. Jobert has seen 
perforation of the olecranon and of the patella; Larrey, of the 
cervix femoris ; cases of it in the condyles of the femur, and in the 
head of the tibia, are quite numerous; Dupuytren mentions one 
of the calcaneum; and the perforations of the carpus and tarsus, 
en masse, are innumerable. Commonly the ball lodges in the bone, 
and the perforation is incomplete ; more rarely the bone is traversed 
through and through. 

The mechanism of incomplete perforations has been studied by 
Dupuytren, by firing at subjects cased in plaster. If the ball strikes 
the surface perpendicularly, it penetrates to a variable depth, form- 
ing an excavation, or sort of conical channel, of which the external 
opening, the narrowest part, is of the same dimensions as the ball. 
The ball is then free and movable at the bottom of this excavation, 
while the narrowness of the orifice fully explains the dfficulty often 
met with in its extraction. Complete perforations have been imi- 
tated by firing at boards, either single or placed upon one another; 
when a ball passes through, the orifice of entry is always less than 
that of exit, contrary to what happens when it goes through the 
soft parts. 

If we examine the course of a ball shortly after the receipt of the 
injury, we perceive in all cases, according to Jobert, rough bits of 
bone, sometimes entirely separate and sometimes adherent, some- 
times small and like mere rugosities, sometimes at once broad and 
long; at the level of the orifice of exit, they are more numerous, 
more closely packed, and more freely bathed in blood. These are 
the debris of the bone, broken off by the ball and pushed before it. 

These perforations are generally serious. The surrounding soft 
parts swell and inflame; the bone itself shares in this action; the 
limb becomes cedematous above and below; a copious, fetid, reddish 
suppuration flows from the opening or openings in the bone ; a probe 
introduced into the substance of the bone shows it to be softened 
and easily penetrated. By degrees the splinters are detached and 
floated out in the pus ; but this does not remedy the evil ; caries is 
developed, extending in different directions, sometimes involving the 



A TREATISE ON FRACTURES. 61 

neighboring bones, and often giving rise to fistulas and interminable 
suppuration, against which amputation is the last and only resource. 

At other times nature is stronger, and after throwing out the 
splinters, sets to work to fill the empty space in the bone, and to 
heal the wound by a good firm cicatrix. Some patients purchase 
this result more dearly, at the expense of numerous abscesses suc- 
cessively forming for the extrusion of forgotten splinters. There 
are, lastly, those in whom the healing occurs as easily as after the 
simplest wound; neither necrosis nor separation of splinters takes 
place, but healthy suppuration soon gives rise to granulations, filling 
up the loss of substance in the bone. M. Jobert has seen such re- 
coveries in perforations of the carpus and tarsus, and even of the 
bones around the knee-joint. M. Paillard witnessed, at Antwerp, a 
result quite as successful in a patient who had received a ball in the 
substance of the external condyle of the femur. 

The extraction of the ball is, doubtless, an important step toward 
such an event; but it is not an indispensable condition. In the 
patient whose humerus I have had drawn, {Fig. 3,) the ball was 
lodged in the head of the bone, where it had hollowed out a space 
three or four times its own size; probably it was inclosed in a 
fibrous cyst ; certainly, however, the humerus displayed no trace of 
morbid change either in the cavity in its head, or at any other point. 
In another specimen, (Fig. 16,) numerous grains of shot were found 
inclosed in the callus of a fractured jaw, firmly imbedded in the 
osseous tissue. Larrey has given the history of an officer of the 
army in Egypt, who received, at the siege of Alexandria, a ball in 
the substance of the cervix femoris; the wound cicatrized; twenty 
years after, the patient dying of an affection of the chest, the ball 
was found in the osseous tissue, where it had so long quietly re- 
mained. 

Strange as it may seem, these lesions have been met with even in 
the diaphyses, but less frequently, the compact tissue being more 
easily broken into splinters than perforated in this manner. Some- 
times the ball, flattened and changed in shape by striking the bone, 
imbeds itself in its tissue without penetrating to the medullary canal; 
but this seems to be very rare. I have, however, many times seen 
in the Museum at Val-de-Grace, a humerus, struck at the middle by 
a ball which remained incrusted close to the surface ; unluckily, this 
interesting specimen has been lost. In the tibia, (No. 221,) in the 
Musee Dupuytren, already mentioned in connection with fissures, is 
seen also the impression made by the ball which was arrested in it.* 
Oftener the ball traverses the wall of the medullary canal, in which 
it lodges, as we have said one did in the frontal sinus, sometimes 

* I presume this specimen belongs to Obs. 30 of the Traits des Blessures 
par Arraes de Guerre of Dupuytren, tome i, p. 316. 



62 A TREATISE ON FRACTURES. 

maintaining its form and size, sometimes flattening itself against 
that wall which is yet intact, so that its orifice of entry becomes too 
narrow for its exit. Percy states that he obtained incomplete per- 
forations of the diaphyses by eight out of two thousand shots fired 
at dead bodies ; the bones thus penetrated were the femur, tibia, and 
humerus. In clinical experience, it is almost always the tibia that 
is involved, rarely the humerus ; I have not seen a single instance 
in the femur. Lastly, the rarest case of all is that of complete per- 
foration of a diaphysis. Percy mentions, indeed, Schligting's case, 
where a ball went through and through the femur, without splinter- 
ing it at all; but he forgets the important point, namely, how high 
up the ball struck. I have succeeded in finding but two well-authen- 
ticated instances. The first belongs to Dupuytren ; a young con- 
script of 1814, had a ball pass through his leg; he soon after 
died, at the Hotel-Dieu. At the autopsy, the tibia was found com- 
pletely perforated at the junction of the upper and middle third, the 
two orifices showing no trace of any fracture. The second case, 
still more curious, and likewise recorded in Dupuytren's work, was 
that of one of the men wounded in July, [during the Revolution of 
1830,] who was struck in the right forearm by a ball, which went 
through the ulna at the junction of its upper and middle third; he 
recovered, but only after a long time, and after several splinters had 
come away. 

The theory of these perforations is far from being established on 
a firm basis. Even in the spongy tissue, how shall we explain the 
irregularity of the results ; there being sometimes mere incrustation 
and change of shape of the ball, sometimes perforation, complete or 
incomplete, and most commonly splintered fracture? And the dif- 
ficulty is greater still for the compact tissue of the diaphyses. I 
shall not go over the hypotheses which have been brought forward 
on this subject; what concerns our purpose is the reality of the 
facts. 

One would suppose that the presence of a ball within the medul- 
lary canal would induce much graver symptoms than in the spongy 
tissue. Doubtless either injury is dangerous, but one not much 
more so than the other. Larrey has seen patients carry balls for 
many years in the medullary canal of the tibia; to be sure, they 
had obstinate fistulous ulcers, and at last amputation became neces- 
sary; but Bilguer states that he cured a soldier who had a ball in 
the medullary canal of the humerus, to the extraction of which this 
willful patient would not consent ; and Percy says he knew an old 
carabineer who carried one twenty-five years in the middle of the 
tibia; it was found at the autopsy in the centre of an exostosis, of 
which it had been the nucleus. 

We should note these fortunate cases, as evidences of the power of 
nature ; but they hardly serve to modify the gravity of our prog- 



A TREATISE ON FRACTURES. 63 

nosis when we have not succeeded in extracting the ball; and hence 
the essential indication in cases of this kind, viz., the removal of 
the foreign body. 

This indication, then, stands first; but M. Jobert has proposed an 
exception to it, of which I approve. Suppose a ball lodged in the 
substance of the clavicle, should we persist in removing it, at the 
risk of breaking the bone? It seems to me that between the danger 
of letting the ball remain, and that of completing the fracture, there 
is room for doubt which is most serious, and that the decision should 
depend on the importance of the bone and the position of the ball. 

Extraction being decided on, it should be accomplished by the 
usual well-known means. Sometimes the orifice of entry is too 
small to allow of the free exit of the projectile; in a case of this kind 
Desport used a trephine, to remove a ball from the tibia. When the 
perforation is complete, it is still useful to examine whether there 
has not lodged in the track of the ball some foreign body, such as a 
bit of clothing, as occurred to Dupuytren's conscript. The wound 
being well cleared, the treatment should be the same as that of com- 
plete fractures of the same kind; and every one must see how much 
the solidity of a bone thus preserved will add to the chances of success. 

§ II. — Of Complete, Simple Fractures. 

I shall arrange under this head likewise four important varieties, 
viz., (1) transverse fractures ; (2) serrated ; (3) oblique ; (4) separa- 
tions of epiphyses. 

(1.) Of Transverse Fractures. — Fractures of this kind have been 
recognised from the earliest antiquity; they hold a place in all trea- 
tises on surgery. Boyer says, indeed, speaking of the tibia, that 
fracture of this bone is almost always transverse; it may, therefore, 
seem strange enough for the reality of transverse fractures to be 
called in question, or denied. 

There is, however, in the classical authors, a confusion which must 
be first explained. They use as synonymous the terms " transverse 
fracture" and "fracture en rave,'" which differ from one another in 
several respects. For a fracture to be en rave, it needs only that 
the fractured surface should be even, and should involve the opposite 
faces of the bone at the same level. [That is, at the surface, the 
line of fracture should be transverse, however irregularly the bone 
may be separated within. The applicability of the term en rave, 
radish-like, will be appreciated by any one who remembers the 
manner in which a radish snaps off when bent.] Thus the frac- 
ture of the acromion, represented in Fig. 25, appears to have been 
properly en rave, although it could hardly be called transverse. The 
perpendicular fracture of the lower jaw, said to have been observed, 
would also be en rave; and likewise the vertical fracture of the patella, 



64 A TREATISE ON FRACTURES. 

or certain other fractures with even surfaces, passing obliquely into the 
articulations. The spongy portions of the hones may offer fractures 
en rare in different directions; and the fracture of the lower end of 
the radius may even he very nearly both en rave and transverse, 
although with some superficial serration. (See Fig. 56.) But the 
main question is concerning the diaphyses; and I may say at once 
that I have never seen, either in museums or in clinical experience, 
and that I have never been able to produce in my experiments, a 
single case of transverse fracture of a diaphysis. 

I would not, nevertheless, omit to state that M. Denonvilliers, in 
his description of the fractures in the Musee Dupuytren, notes four 
or five as transverse, chiefly among those of the lower third of the 
femur. I have, consequently, felt obliged to examine those speci- 
mens with the greatest care; and I have assured myself that of 
them all, the one least open to suspicion, (fracture of the femur, No. 
135,) in spite of the callus masking its primitive character, bears 
features irreconcilable with the idea of a transverse fracture. 

After examination of the three great museums of Paris, after re- 
peated experiments on dead subjects of all ages, even upon the foetus 
before term, I had firmly denied the existence of transverse fractures 
in the diaphyses, and believed myself to be alone in this opinion, 
when I discovered a vigorous champion who had before sustained it, 
and who, though depriving me of the priority, gave me in return the 
support of his judgment. Camper had visited the museums of Ger- 
many, England, and Holland, and had arrived at the conclusion that 
neither transverse fracture nor fracture en rave had ever been observed 
except in the patella, and that the long bones were always broken 
either obliquely or longitudinally.* Cases which Camper had not 
seen have authorized me to extend greatly the range of fractures 
en rave ; and my experiments on the dead body, added to autopsies 
of recent fractures, also lead me to oppose his assertion touching the 
direction of other fractures. In the museums he had seen hardly 
any but old fractures, quite consolidated ; which would indeed justly 
testify against the transverse direction, but would not show so well 
their real primitive course. A very large class of fractures, omitted 
by Camper and by all modern surgeons, is composed of such as are 
serrated. 

(2.) Serrated Fractures. — I mentioned first in 1838, in my Me- 
moire sur les Fractures des Cotes, these serrated fractures, which I 
have also observed in the clavicle and humerus ; and I was not a 
little surprised afterwards to find them spoken of under the same 
name by A. Pare, thus in advance of his own time. My researches 
now enable me to give a far more complete account of them. 

In trying to break the bones of a corpse by a direct blow, in place 

* Camper, Obs. circa Callum, op. cit. 



A TREATISE ON FRACTURES. 65 

of the transverse fractures I sought to produce, I only obtained, in 
the immense majority of cases, toothed fractures ; that is to say, 
fractures with surfaces set with irregular, angular, pointed projec- 
tions, so dove-tailed as most frequently to prevent either displace- 
ment or crepitation, the lesion being only recognised by an abnormal 
flexion at the part involved. If the force of the blow produced 
an incomplete transverse displacement, I found that this was fa- 
cilitated by the breaking of some of these projections, forming so 
many little splinters ; but there remained enough of them to hold 
the two fragments together. Still, owing to the abnormal impac- 
tion of the angles of the fragments, it was almost equally difficult 
either to complete or to reduce the displacement, even in the dead 
body. When the displacement was complete, reduction was still 
more troublesome, from the difficulty of fitting each projection ex- 
actly into its corresponding angle. 

These phenomena were so singular that I could not but seek to 
verify them in fractures occurring during life. I examined, therefore, 
with more care than ever, the symptoms and anatomical conditions 
of recent fractures, and was not long in establishing their conformity 
with the results of my experiments. I believe, then, that I can lay 
down the general law that the majority of simple fractures from 
direct blows are serrated, varying in the living as in the dead ; that 
is, showing complete or incomplete displacement, or none at all ; but 
in the two former cases, presenting a difficulty of reduction much 
increased by muscular resistance. I shall mention again, hereafter, 
that oblique fractures themselves are very often serrated, and that 
certain comminuted fractures are nothing more than serrated frac- 
tures, in which a large projection has been broken off by the same 
force, thus becoming a separate fragment. 

Does indirect violence also give rise to fractures of this kind ? On 
this point experiment is almost silent, indirect fractures being by no 
means easy of production in the dead body ; but, according to what 
I have seen during life and at autopsies, it appears that such violence 
far more frequently gives rise to oblique fractures; and thus that 
each order of causes has its own proper results, to which it is, so to 
speak, privileged. 

I have observed these fractures in the clavicle and in the humerus, 
in the radius, alone or together with the ulna; in the femur and in 
the tibia, and moreover at all ages. When I took, for example, the 
wards of M. J. Cloquet, in 1842, they contained but two fractures, 
both of which were from direct violence: the one was in a young 
boy, the other in a man ; the former involved the humerus, the latter 
the radius; both, presenting neither displacement nor crepitus, had 
been recognised only by the preternatural mobility; these were 
striking examples of serrated fractures in the very simplest form. 

Serrated fractures with partial displacement are especially easy of 

5 



bb A TREATISE ON FRACTURES. 

diagnosis, during life, in the ulna and in the tibia. It is by no means 
rare, in practising surgery, to meet with fractures of the tibia with 
a slight prominence of one of the fragments, not tending to increase 
at all, but resisting all attempts at reduction ; of this I could cite 
numerous instances. It is evident that in the femur, and wherever else 
the fracture is buried within a mass of muscle, these slight displace- 
ments are less easily perceived. I have had represented a very 
beautiful example of this, from the Muse'e des HOpitaux. (See 
Figs. 15 and 76.) 

As for complete displacements which cannot be reduced, it has 
become customary to attribute them to oblique or comminuted frac- 
tures. I should say that they are very often the result of serrated 
fractures. There may be seen, in Fig. 6, a very beautiful fracture 
of the femur, produced by a fall from a height, in an old man, who 
died some days after from concussion of the brain ; there was com- 
plete displacement with overlapping, which all my efforts were unable 
to reduce. At the autopsy, I found the fragments shaped as repre- 
sented, excepting two small splinters, which were found buried in 
the muscular substance. 

Serrated fractures being so common, — the most common, indeed, 
of all, — it remains to be explained how they have hitherto escaped 
the notice of observers. Experiments and autopsies conducted with 
too little care, and, to speak freely, with too blind a faith in the 
dicta of great authorities, have doubtless caused this strange over- 
sight. In the living subject, notwithstanding their characteristic 
symptoms, we confound them with other varieties ; and a word must 
be said in reference to these errors in the differential diagnosis. 

When the fragments remain in apposition, we can only recognise 
serrated fracture by one of these phenomena : either by the possibility 
of bending the bone at the seat of fracture, or by the flexion already 
produced, either by the determining cause or by the weight of the 
limb. Now these two characters belong also to partial fractures, 
properly so called ; and hence a confusion not always easily avoided. 
Sanson observed, for example, a fractured clavicle in which there 
was a considerable angular projection at the middle ; the fragments, 
separated above, had kept their level below ; crepitus could not be 
elicited. From these circumstances he diagnosed a partial frac- 
ture. I have twice seen similar cases ; and one of the patients dying, 
I was enabled to prove by dissection the existence of a complete, 
serrated fracture. Raleigh, again, being called to a child which had 
sustained a fall, found the arm swollen, the only other sign of frac- 
ture being that he could bend it at the middle ; hence he considered 
it an incomplete fracture.* I have three times seen this in the 

* Sanson, art. Fractures, etc. ; Kaleigh, Gazette Me'dicale, 1836, p. 282. See 
also, in the same volume, p. 50, my report of the dissection of a serrated fracture 
of the clavicle. 



A TREATISE ON FRACTURES. 67 

living subject. I have quite often caused it in the dead body ; and 
dissection then showed sometimes partial fracture, but much oftener 
one which was complete and serrated. 

As far as I can judge on a question still so new, angular bending, 
easily corrected, of a bone, belongs essentially to complete fracture ; 
difficulty of reduction indicates that the bone is only partly broken. 
In cases where the bone maintains its form, bending only under force 
intentionally applied, if this bending occurs but in one direction, and 
that to a very limited degree, the fracture is only partial ; more ex- 
tended flexion, taking place in different directions, would denote com- 
plete fracture. But, besides that the periosteum may oppose resist- 
ance to flexion in some directions, even when the bone is entirely 
divided, there are cases in which the relations of the bone permit of 
its bending only in one direction, and to a very slight degree ; thus 
the radius cannot be much bent except when separated from the 
ulna, nor can the fibula except when separated from the tibia, etc. 
To sum up, a careful examination will often establish the differential 
diagnosis ; but I cannot say that this may be done in all cases. 

When the fragments have sustained partial lateral displacement, 
the fracture has generally been pronounced en rave, it being forgot- 
ten that in that case reduction would be easy. Before discussing the 
differential diagnosis, it would be well to await proof of the existence 
in the diaphyses of these fractures en rave ; but meanwhile let me 
not pass over one circumstance which may lead to error. It is not 
uncommon, in examining the internal face of a broken tibia, to dis- 
cover a perfectly regular, transverse solution of continuity, without 
serrations ; and hence, doubtless, Boyer's assertion concerning this 
bone. But experiment sifts all these things. I have more than 
once caused a purely transverse line of separation in the internal 
face of the tibia, so that at first I thought I had obtained an instance 
of this a unfindable" fracture; but on stripping the other parts from 
the bone, and separating the fragments, I have always discovered 
numerous dentations on the other surfaces and in the thickness of 
the bone. The so-called fracture en rave existed only at the sur- 
face ; and I note this as so much the more remarkable, since I never 
have been able to observe similar appearances in any other diaphysis, 
nor even on the other two surfaces of the tibia. 

When, lastly, complete transverse displacement induces overlap- 
ping, and we are to determine whether the fracture is serrated or 
oblique, the only resource is to examine the ends of the fragments 
by means of the fingers. Suffice it to say that we cannot arrive 
certainly at the differential diagnosis except in fractures of super- 
ficial bones, and that in those deeply seated the form can only be 
revealed by dissection. 

(3.) Of Oblique Fractures. — Oblique fractures vary much, accord- 
ing to the degree of their obliquity. Strictly speaking, very few 



08 A TREATISE ON FRACTURES. 

so-called transverse fractures of the patella have not a certain degree 
of obliquity ; and this obliquity is still more marked in fractures of 
the olecranon. In the long bones, the generic name of oblique frac- 
tures is usually restricted to such as have an angle not far from 
45°. If the obliquity is greater, they become fractures en bee de 
flute. [By bee de flute is meant the reed or mouth-piece of a clario- 
net. The application of this comparison to many fractures will 
be at once evident.] If they approach parallelism to the axis 
of the bone, they are called longitudinal fractures. M. Cam- 
paignac has given the case of an old man who died on the twelfth 
day after sustaining a fracture of the femur. At the autopsy, a 
fracture was discovered beginning at the middle of the bone, and 
running up to a point above the lesser trochanter, its extent being 
about four and one-third inches. I have an analogous specimen, in 
which the fracture passes up from within outward to a nearly equal 
extent. But the most remarkable case which can be cited of this 
kind, is certainly that presented by M. J. Cloquet, in his These du 
Concours. It is the femur of a slater who fell from a roof. The 
fracture, commencing between the two condyles, runs up inward to 
the level of the lesser trochanter, its length being about ten inches. 
These are, however, quite rare cases ; and it is perhaps not out of 
place to mention that they have hardly been met with except in the 
femur. 

[A man was crushed by the caving in of a bank of earth ; and 
among other injuries, he sustained a comminuted fracture of the left 
femur. An abscess formed in this thigh, of which he died some three 
weeks after. The autopsy showed a complete fracture about three 
inches below the trochanters. From the upper part of this there 
ran two longitudinal fractures, one anterior and the other posterior. 
The latter ascended to the lesser trochanter ; the former ran also 
upward and inward to the lesser trochanter, and then, changing its 
direction and becoming a mere fissure, passed upward and outward 
to the apex of the trochanter major. Here was a genuine longi- 
tudinal fracture, with fissure also.] 

As to ordinary oblique fractures, they are sometimes produced by 
direct, but more frequently by indirect, violence ; and perhaps they 
have something peculiar in their aspect, according to the cause pro- 
ducing them. Examine, for example, (Fig. 5,) an oblique fracture 
of the humerus, produced by direct violence on the dead body. It 
presents, on its two extremities, serrations, which should have been 
broken off to give it an unmixed obliquity. Contrast with this an 
indirect fracture of the clavicle, (Fig. 17.) This is really a clean, 
sharp, oblique fracture, undoubtedly to be called a fracture en bee de 
flUte. In the majority of fractures of the leg from falls on the feet, 
we can feel under the skin this sharp point, en bee de flUte — if, in- 
deed, it has not made its way through the integuments ; and I would 



A TREATISE ON FRACTURES. 69 

recall here the three longitudinal fractures of the femur before men- 
tioned, all arising from indirect violence. 

(4.) Separation of the Epiphyses. — I rank among fractures these 
lesions, which some modern authors would consider as distinct 
from them, because they acknowledge the same causes, present the 
same symptoms, call for the same treatment, and lastly cannot 
always be exactly distinguished from fractures properly so called. 

On the strength of an equivocal word, an attempt has been made 
to date back the recognition of this lesion to the time of Hippocrates. 
On the contrary, it may be regarded as certain, that Colombo was the 
first to point out its possibility in the sixteenth century; and the 
slight mention made of it by Pare* cannot be thought by any means 
positive. At best, there were on this point only conjectures and 
doubts, since in 1759, Reichel put forth a long thesis with three 
pathological specimens, unaccompanied by details of their history ; 
these specimens would seem to have been simply fractures which had 
occurred in men of very advanced years. We must then come down 
as far as 1787, to find in a chapter of Bertrandi some separations 
of epiphyses, established by dissection. 

u l had occasion," says he, "to open the body of a child which had 
died in the uterus from the midwife pulling upon an arm protruding 
from the vagina, and found the head of the humerus separated from 
the shaft of the bone ; and in another child which was found after ■ 
its birth to have one leg shorter than the other, I observed the 
femur luxated, its head still remaining in the cotyloid cavity." It is 
plain that Bertrandi' s terms are not rigidly accurate, nor are his facts 
much more so. Thus we read, a little farther on: "I have seen in 
the body of a child, at M. Sue's, in Paris, the head of the humerus 
united with the neck of the scapula, and the glenoid cavity hollowed 
out in the end of the humerus, from separation of the epiphyses 
occurring three years before. The motions were not impaired ; 
but one could not always look for equal success." To affirm in- 
tegrity of the movements from merely examining the corpse would 
show some temerity; but with the new articulation described by 
the author, such an assertion exceeds the limits of probability. 

We may presume that these first attempts left some doubt in the 
minds of surgeons, and that Delpech, in 1816, believed himself 
correct in denying the possibility of detachment of the epiphyses. 
More recently, M. Rognetta and M. Gue'retin have resumed the 
subject in two very interesting memoirs; in which, however, we must 
regret finding some facts misinterpreted, which are irrelevant to the 
question, and some others omitted which would have shed much 
light upon it.* 

* See Reichel's Thesis, in the Thesaurus DisseHationum of Sandifort, vol. i ; 
M. Rognetta's Memoir in the Gazette Mtdicale, 1834 ; and that of M. Gu6retin 
in La Presse Mtdicah. 



70 A TREATISE ON FRACTURES. 

The decollation of the epiphyses has been established by dissection : 
(1) at either extremity of the humerus ; (2) at the inferior extremity 
of the radius ; (3) at either extremity of the femur ; (4) at either ex- 
tremity of the tibia. M. Gue're'tin says also that he has succeeded 
in separating the olecranon in the bodies of children ; and these are 
all the facts on this subject, at present possessed by science. In- 
stances are indeed cited of decollation of other epiphyses, but only 
in the living body, and it is more prudent to rely entirely upon dis- 
sections. I shall bring up, in connection with particular fractures, 
the facts concerning decollation of the epiphyses of each bone ; but 
it will be useful to study first the general subject. 

These decollations have been observed mainly during the period 
from birth to fifteen years of age. At birth they are generally 
caused by inconsiderate traction on the limbs. M. Champion saw, 
in 1810, separation of the lower extremity of the left tibia, in a 
child at term, by violent pulling on the foot. Madame Lachapelle 
gives a similar case, from a like cause : and another in which the 
traction on the foot separated at once the inferior epiphysis of the 
femur and the superior epiphysis of the tibia. In these three cases 
the children were born dead, as well as in the instance cited by Ber- 
trandi of decollation of the humerus. A similar separation was 
made out by Chapelain Durocher, in a child which survived for four- 
teen months ; the midwife caused it by hooking her finger in the 
armpit to assist the delivery.* After birth, also, it requires violent 
traction, or falls, to produce these decollations ; there are no exam- 
ples of such results from direct blows. M. J. Cloquet dissected 
a separation of the inferior epiphysis of the radius in a child of 
twelve years, who had fallen from the top of a tree. M. Rognetta 
gives a similar case, occurring in a subject fifteen years old. M. 
Coural was obliged to amputate the thigh of a child eleven years old, 
for a separation of the inferior epiphysis of the femur, caused as 
follows : the child got its leg into a hole, as far as the condyles of 
the femur, and the impulse threw the rest of the body forward. f As 
to traction, M. Champion has given two remarkable examples, also 
in boys from eleven to thirteen years old. One had his arm caught 
in the spokes of a wheel, and the other had his forearm entangled in 
a carding-machine. In the former there resulted separation of the 
superior, and in the latter, of the inferior epiphysis of the humerus. 

An external injury may likewise separate the epiphyses of a yet 
undelivered foetus ; but such cases are very rare, for I know of no 
other example than that of Carus, before mentioned (p. 39.) There 

* Champion, Journal CompUmentaire, tome i, p. 317 ; Mme. Lachapelle, 
Pratique des Accouch., tome ii, p. 225, and tome iii, p. 180 ; Chapelain Duro- 
cher, TJiese Inaugurate, 8vo, Paris, 8 Frimaire, an xii. 

t J. Cloquet, art. Fractures, Diet, en 30 volumes ; Rognetta, op. tit.; Coural, 
Archiv. de M6decine, tome xi, p. 267. 



A TREATISE ON FRACTURES. 71 

remains one more question : namely, whether such separations can 
take place above fifteen years of age ; and if so, up to what period of 
life ? There have been examined subjects twenty-five years old, in 
whom the epiphyses were as yet unconsolidated ; hence their separa- 
tion would be possible at this age, although we know of no instances 
of its occurrence above that of fifteen. Against this view, M. De- 
villiers has published the very extraordinary case of a separation of 
the superior epiphysis of the femur in a man fifty-eight years old ; 
but I apprehend some mistake in this case. An old soldier was 
picked up drunk in the fosse of the Bastile. He had pain from the 
right hip down to the foot ; no apparent contusion, and no shorten- 
ing, but indistinct crepitation during abduction. After remaining 
more than a month in the hospital, the patient, walking about and 
free from suffering, requested his discharge, when he was attacked 
by an adynamic fever, which carried him off in a few days. At the 
autopsy, the head of the bone was found separated from the cervix, 
and the two irregular surfaces presenting prominences and depres- 
sions exactly fitting one another. Both were incrusted with a whitish 
substance like inter-articular cartilage, but extremely thin, and at 
some points deficient. The head of the left femur was completely 
ossified with the neck.* All these particulars apply perfectly to an 
intra-capsular fracture without displacement and without any union ; 
and this explanation seems much more probable than the other. 

It may be observed that all these autopsies were made upon male 
subjects ; I may add, also, that among the cases of it observed during 
life, in which the diagnosis seems best established, there is not one 
female. I content myself with stating this circumstance, leaving its 
explanation to others. 

The symptoms of decollation of the epiphyses do not differ from 
those of simple fracture in the vicinity of joints. If there is no dis- 
placement, we can only suspect its existence ; if there is displace- 
ment, according to the extent of this do we easily recognise the 
fracture, or confound it with luxation. But this is a general ques- 
tion of diagnosis, to be treated of hereafter. 

Supposing, then, the solution of continuity to be clearly made out, 
is it possible to determine whether it is a fracture or a separation of 
the epiphysis ? I believe not. Doubtless, when the accident occurs 
before the age of fifteen, when the solution of continuity is on a 
level and in the same direction with the epiphyseal cartilage, the 
presumption is in favor of the decollation, but certainty can only be 
arrived at by an autopsy. It has been thought that absence of cre- 
pitus was characteristic of decollation ; but in many fractures near 
joints crepitus is wanting ; as, for instance, it often is in those of the 
lower extremity of the radius. Let us see, also, to what conclusion 

* Journal CompUmentaire, tome ii, p. 362. 



72 A TREATISE ON FRACTURES. 

M. Gudrdtin has been led by his experiments, made with the express 
object of separating the epiphyses. At the age of nine months, this 
was obtained in one out of four attempts ; the other three causing 
true fractures. From two to seven years, decollation occurred once 
in nine times ; the rest being either fractures or luxations. . From 
seven to fourteen, of ten attempts not one succeeded ; fracture or 
luxation being always caused. To this it must be added that, beyond 
the age of two years, decollation is rarely perfect ; there being , 
nearly always a fragment, greater or smaller, detached by actual 
fracture from the diaphysis, and remaining adherent to the epiphysis. 
This last result is confirmed by autopsies. In the boy thirteen years 
old, with separation of the lower epiphysis of the humerus, M. Cham- 
pion noticed that the outer and posterior part of the epiphysis had 
carried with it a small bit of the diaphysis, the size of the nail, half 
an inch in width, and one-quarter of an inch in thickness. In another 
separation of the upper epiphysis of the humerus, preserved in the 
Musee Dupuytren, I likewise ascertained that the epiphysis had car- 
ried with it a small splinter of the external face of the diaphysis. I 
have had this specimen represented. (See Fig. 4.) The diaphysis 
is displaced inward, overlapping by several millimetres the level of 
the epiphysis. Externally are seen the long flaps of periosteum, 
torn from the neck of the bone, and still attached to the epiphysis. 
In one point the periosteum is raised up by a part of the bone which 
could not be shown in the drawing, but which is easily recognised 
in the specimen, and which forms the splinter alluded to. 

In the other autopsies known to us, there is no mention of similar 
splinters. Does this imply that the separation was simple, and 
without fracture ? We may so much the more reasonably doubt it, 
since in this second specimen M. Champion himself did not see this 
splinter, which escaped likewise the examination of M. Denonvilliers. 
Besides these little concomitant fractures, slight as the displacement 
was, the periosteum was stripped from the diaphysis to a great extent. 
Fig. 4 gives a very good idea of what may occur in this way. 

How are these decollations reunited ? From observations made on 
the living subject, the reparative process goes on as well and as quietly 
in them as in simple fractures. I have had to treat separation of 
the lower extremities of both radii in a child six years old; consoli- 
dation ensued in the usual time and without deformity. I have also 
seen a separation of the head of the humerus, sustained at an early 
age, and united with great displacement; the arm had lost its 
strength, hanging atrophied and nearly paralysed beside the body ; 
but the union, though unsatisfactory, was very solid. In our draw- 
ing, to be sure, no attempt at union is seen ; but the child died on 
the seventh day, in consequence of the very severe local and general 
disorder. 



A TREATISE ON FRACTURES. 73 

Consequently, aside from complications, the prognosis is the same 
as for ordinary fractures near joints. The treatment is likewise the 
same, and need not be detailed here. 

§ III. — Of Comminuted Fractures. 

Under this general head are included four principal varieties : (1) 
fractures with splinters ; (2) fractures of one bone in several places, 
that is, with several fragments; (3) fractures by crushing; and (4) 
fractures involving several bones at once. 

(1.) Of Fractures ivith Splinters. — By splinters are meant small 
fragments separated from the bone, comprising but a portion of its 
breadth or thickness, and which could be taken away without much 
hindering its consolidation or the recovery of its functions. The 
name fragments is reserved to the more important portions, involving 
the whole breadth or thickness of the bone, and the removal of which 
would be notably injurious. The vagueness of some of the terms of 
these definitions arises from the nature of the things concerned. 
There are cases in which it would be hard to distinguish a fragment 
from a splinter, and vice versa. 

Fractures with splinters occur chiefly in the flat and in the long 
bones ; the thick bones are rather liable to the crushing, to be men- 
tioned presently. Splinters in the flat bones may comprise their 
entire thickness without thereby becoming fragments. Such is the 
case with the small splinter in the centre of the fossa infra-spinata 
of the broken scapula shown in Figs. 22 and 23. But our attention 
at present is claimed especially by splinters of the diaphyses. 

These splinters vary much as to number, size, and form, as well 
as in the mechanism of their production. When there are not more 
than one or two of them, they assume generally the shape of a 
wedge, whose base is toward the surface of the bone. I have been 
able to study pretty thoroughly their origin in fractures from direct 
violence : it is then always by the breaking off of a serration, the 
external violence being severe enough to displace the fragments. 
The serrated fracture shown in Fig. 6 presents small splinters of 
this kind; hut Fig. 5 will give a better idea of the mechanism. Sup- 
posing the fragments in apposition, and an external force tending to 
carry the upper fragment to the right, the little projection on the 
right of the lower fragment will be detached and form a splinter. 
On the other hand, if the upper fragment is thrown to the left, the 
bee de flute, presented by it on the right side, will be broken off; 
thus constituting a splinter of much greater size. This supposition is 
verified in Fig. 7, where may be seen a fracture of the right tibia, 
with a large wedge-shaped splinter at the outer side of the bone; 
here the fracture was by direct violence, from the fall of a cask ; very 
probably the first blow broke the bone obliquely, as in Fig. 5 ; but 



74 A TREATISE ON FRACTURES. 

the pressure continuing, the bee deflate was itself obliquely detached, 
and changed into a wedge-shaped splinter. 

I am inclined to believe that in many cases oblique fractures by 
indirect violence are complicated with wedge-shaped splinters by an 
analogous mechanism, so common is this form of splinter in our 
museums. I have besides seen some examples of it in autopsies. 
Thus, in the oblique fracture of the clavicle shown in Fig. 17, the 
upper fragment has lost its point precisely in the manner mentioned. 

When the splinters are in greater number, they are most fre- 
quently the product of a direct cause acting with extreme violence, 
and by a sort of crushing. Sometimes a beam, or a large wagon- 
wheel, begins by breaking the bone into three fragments, and ex- 
hausts its force in crushing the middle portion. A spent cannon- 
ball, striking the shaft of a bone, mashes it into a thousand little 
pieces, without apparently injuring the skin; this is what especially 
receives the name of comminuted fracture. A ball in full motion, 
striking a long bone, breaks it, splitting and cracking it in all direc- 
tions, as if it were glass; this is fracture en eclats, [like our com- 
mon phrase "breaking a thing into shivers,"] and gives rise to the 
most curious splinters. I have had represented (Fig. 8) some splin- 
ters of a tibia fractured by gunshot, in 1815, which remained buried 
in the muscles for eight years, and were only discharged in 1823 ; 
notwithstanding the absorption exercised on their surface during this 
long space of time, the oddity and diversity of their forms are easily 
seen. 

The history of these splinters is too intimately interwoven with 
that of fractures generally to be dwelt upon at length here ; it will 
come up again in connection with the subject of Terminations. 

(2.) Of Fractures with several Fragments. — These are quite rare, 
and have not hitherto been sufficiently studied. In Fig. 7, besides 
the fracture of the tibia, the fibula is seen to be broken at two dif- 
ferent points ; the cause was the fall of a cask, pressing on the bones 
by a broad surface. I have also had represented a double fracture of 
the humerus (Figs. 35 and 36,) and another of the femur (Fig. 74;) 
but I do not know their causes. Sir A. Cooper has figured a double 
fracture of the humerus, in an old man of seventy-one, who was 
thrown down, striking the edge of a curb;* with only this informa- 
tion, it is not easy to account for the fracture being double, and the 
less, since a direct cause for one portion of it seems to be evident. 

To sum up, I know of no cases in which double fracture has been 
caused in a diaphysis by indirect violence, although I would by no 
means deny the possibility of such a thing. A direct cause acting 
by double pressure, or perhaps the joint effect of a direct and an in- 

* Guy's Hospital Reports, Oct., 1839, p. 232. 



A TREATISE ON FRACTURES. 75 

direct force, seems most frequently to produce fractures of this kind; 
but, I repeat, the question needs further study. 

In large articulating extremities, for instance, there are some 
double fractures from a single indirect cause; such are fractures of 
the condyles of the humerus from falls on the olecranon {Fig. 41;) 
and I have seen several cases of comminuted fracture of the condyles 
of the femur in consequence of falls on the patella. 

(3.) Of Fractures by Crushing. — I shall merely mention here, 
without again recurring to the subject, crushing of the cranial bones, 
or of the bones of the trunk and extremities, caused by falls from a 
great height, by the pressure of powerful machinery, or by the action 
of irresistible violence, as the caving in of a quarry, the explosion of 
a blast, etc. Here not only the bones are crushed, but also the in- 
teguments, muscles and viscera; life is extinguished almost instantly, 
either in the whole organism or in the limb; and in the least des- 
perate cases we have no longer to treat fractures, but to perform 
amputation. 

But I would speak now of a form of fracture, more common 
than is generally supposed, and to which suitable attention has not 
hitherto been paid. It occurs only in the thick bones, and in the 
cancellous extremities of the long bones; but numerous examples of 
it can be cited. It has been observed in the vertebrae; and I have 
had drawn some very remarkable instances of it in the cervix hu- 
meri, in the cervix femoris, in the inferior extremity of the tibia, in 
the calcaneum, and, as I shall have occasion to mention, in yet other 
regions. The essential character of crushing is the reduction of the 
bone into a number of fragments crowded upon one another, with 
condensation, and as it were disappearance, of the intermediate 
spongy tissue; so that at first the bone seems to have sustained a 
loss of substance, without the formation of either splinters or debris. 
The appearance of a bone thus crushed is perfectly displayed in 
Figs. 26 and 27, in the neck of the humerus, and in Fig. 98 in an 
os calcis. The closer study of the mode of condensation of the frag- 
ments will be aided by Figs. 99 and 100, representing a horizontal 
section of the calcaneum and lower articulating surface of the tibia, 
disjointed by penetration of the debris of the spongy tissue; and, 
lastly, in Fig. 68, I have placed nearly in their natural position the 
fragments produced by crushing of the cervix femoris; it is plain 
that even the outer shell of the bone has sustained at several points 
a loss of substance, the debris of which I could not find; through 
this void the eye penetrates (as well as could be shown in a drawing,) 
to the interior of this osseous shell, which is quite empty; and of 
the abundant cancellous substance which should have filled it up, as 
is seen in Figs. 70 and 71, there remain only one or two small 
shapeless bits. 

These ideas may suffice to distinguish what we call crushing, from 



76 A TREATISE ON FRACTURES. 

comminuted fracture, when the bone at the broken part no longer 
preserves any consistence, being found in the form of debris or splin- 
ters lying loosely in the midst of the muscular substance. To make 
the difference more evident, compare the two humeri, or the calca- 
neum, before mentioned, with the comminuted fracture of the elbow 
represented in Fig. 45. Here, by the effect of time and gradual 
absorption, the greater part of the splinters have disappeared; but 
their vestiges remain in the shape of the little rounded osseous 
masses, loosely held in place between the bones by bands of fibrous 
tissue. Examine the lower end of the humerus; look for the head 
of the radius, for the coronoid process of the ulna; all is mashed, 
reduced to small splinters, irrecoverably gone. Thus, then, they 
differ in appearance, in symptoms, and in consequences. Add to 
this that in crushing there is not, properly speaking, any displace- 
ment, the fragments remaining adherent to one another, while in 
comminuted fracture, on the contrary, there is no cohesion of the 
splinters, and displacement is inevitable ; and we see a vast differ- 
ence in their diagnosis, prognosis, and treatment. 

The causes alone are similar, at least in part, and it is difficult to 
say whence arises the variety of result. In both cases it is usually a 
direct shock; a fall on the end of the shoulder, on the elbow, tro- 
chanter major or calcaneum; but sometimes the crushing may also 
result from indirect violence, as for instance in the vertebrae, radius, 
or tibia; which can never be true of comminuted fracture. 

[In the United States there is not generally so great a distinction 
recognised between comminuted fracture and crushing, the differ- 
ence being considered one of degree only.] 

There is another fracture, which in the living subject so much re- 
sembles crushing that it would be difficult to distinguish them; I 
allude to simple fracture of the articular extremities, with more or 
less marked impaction of one of the fragments in the spongy tissue 
of the other. I shall recur to this point in speaking of displacement 
by penetration. The difference is very important in regard to con- 
sequences and to treatment; for mere displacement by penetration 
may be reduced, and all deformity obviated, while it is very doubtful 
if such reduction can be effected and maintained in cases of actual 
crushing. We shall have especially to recur to this subject in treat- 
ing of fractures of the lower end of the radius, and of the cervix 
femoris. 

(4.) Of Fractures involving several bones at once. — This subject 
has hardly attracted the attention of any observers. It is, indeed, 
mentioned in treating of fractures of both bones of the forearm or of 
both bones of the leg; but without any distinction from simple frac- 
tures, and the only question raised regarding them has been whether 
they should be called complete [complicated?] or compound. There 
is surely something more here to be studied; and first, to fractures 



A TREATISE ON FRACTURES. 77 

of the forearm and of the leg should be added those involving several 
ribs, constituting a group, viz., of such fractures as involve several 
parallel bones; secondly, another group includes cases where frac- 
tures are distributed among several bones more or less removed 
from one another. 

The first point of inquiry is, in what proportion do these frac- 
tures occur, compared with others; and in regard to the first group, 
it is nearly impossible to determine this from our present knowledge. 
In no statistics has the attempt been made to divide cases in which 
one rib was broken from those involving several ; and too often sur- 
geons confound, under the vague title of fractures of the forearm or 
leg, such as are strictly limited to one of the bones. I have, indeed, 
in my general tables (see page 23,) placed separately fractures, for 
instance, of the tibia from fractures of the leg ; but these figures are 
evidently relative and unreliable, and I find them no more certain 
in other similar tables. 

As for multiple fractures of the second group, I have already said 
that there were thirty cases in a total of 2358 patients ; to repeat, 
they are as follows : — 

Fractures of both legs 9 

11 the thigh and leg 3 

" " thigh " arm ------ 3 

" " thigh " forearm ----- 2 

" " thigh " clavicle 1 

" " arm " skull - 3 

" " skull, thigh and leg 1 

" " skull, thigh " arm ----- 1 

" " skull, thigh " forearm - 1 

" " skull, thigh, leg and pelvis 1 

" " vertebrae and leg 1 

" " vertebrae " both legs 1 

" " vertebrae, thigh and ulna - 1 

" both clavicles 1 

" one clavicle and the ribs - - - - - 1 

I have sought in this enumeration to observe some order, following 
especially the degrees of frequency; and we find that these thirty 
patients sustained in all sixty-seven fractures; one alone had four; 
six had three, and the rest had each at least two. I say at least, 
since fractures of the leg, of, the forearm, and of the ribs are each 
counted here as single fractures. The most frequent were : — 

Of the leg 26 

" " thigh 14 

" " arm 7 

" " skull 7 

" " clavicle 4 

" " forearm 3 

" " spine 3 



78 A TREATISE ON FRACTURES. 

From this simple statement it may be concluded that falls are the 
most frequent causes of these multiple fractures; there are hardly 
any but those of both legs, of the clavicle, and of the ribs, which can 
be attributed to direct violence ; and it is curious enough to note 
this difference between multiple fractures of single bones, which ap- 
pear generally to depend on causes of this sort, and those of several 
bones, which show an etiology just the opposite. 

One would suppose that in all cases the danger to the patients 
would increase with the number of fractures ; but when the cause is 
a fall from some great height, to this first danger is added another, 
arising from visceral injury, or from general shock. The prognosis 
is then very serious, few patients recovering under such circum- 
stances. If, however, the symptoms of shock pass off, there occurs 
a very remarkable phenomenon pointed out by Dupuytren ; it is one 
of his ideas which I have happily saved from oblivion. He says 
that the danger of wounds and of fractures, although doubtless in- 
creased by an increase in their number, is still not in direct ratio 
with that number. At first sight, one would presume that several 
fractures complicating one another would mutually react unfavora- 
bly, each one thus giving rise to graver symptoms than if it had 
occurred alone. Now, the contrary is true; when there are several 
fractures, each one induces slighter symptoms than if it were by 
itself; and Dupuytren, after at first viewing this fact with astonish- 
ment, became assured of it, and looked for it subsequently as na- 
tural, and to be expected. I repeat that the danger is always 
greater for the patient, but less for each particular fracture; inflam- 
mation is less to be feared, and consolidation more readily occurs. 
Cannot this be explained by the supposition that the vital force is 
then distributed, so as not to excite around each fracture the amount 
of reaction which would take place around it if solitary?* 

I have followed out this idea, which would perhaps find a more ap- 
propriate place under the head of Prognosis, to show that the special 
study of multiple fractures is possessed of real interest, and that it has 
already been of advantage. As to fractures of parallel bones in par- 
ticular, we have to fear a blending of the callus, almost without in- 
convenience in the leg, but too frequently troublesome in the fore- 
arm ; of this, as occurring in the ribs, I have given a fine example 
in Fig. 9. We shall recur to this in examining Special Fractures. 

§ IV. — Of Complicated Fractures. 

Fractures consisting essentially and exclusively in a division of the 
bone, it follows that any accompanying lesion, either in the surrounding 

* Gazette Medicate, 1832, p. 394. 



A TREATISE ON FRACTURES. 79 

parts or in the economy at large, should be properly considered a com- 
plication. Thus, among the local complications would rank the bruis- 
ing or tearing of the periosteum, of the muscles, of the aponeuroses, 
of the vessels, nerves and skin; injuries to the joints, either by com- 
munication with the fracture or by luxation; and lastly, visceral 
mischief, whether caused by the original violence or by the frag- 
ments themselves. Thus also we should rank as general complica- 
tions, traumatic fever, all coincident internal inflammations, and 
lastly cachexies or diatheses. But bruisings and even lacerations of 
the periosteum and of the muscles are so frequent in cases of frac- 
ture, that it has become customary to look on them as associate phe- 
nomena rather than as complications ; and so also of traumatic fever ; 
moreover, internal inflammations have been regarded as simply co- 
incident, although their influence upon consolidation exceeds even 
that of diatheses and cachexies ; so that the number of complications 
is greatly lessened. Even the passing of a fracture into a joint has 
been excluded here, and called a variety merely of fracture; and 
lastly the English surgeons have ended by limiting the denomination 
of complicated [compound] fractures to those which communicate by 
a wound with the external air. 

[It is difficult to understand how M. Malgaigne can have fallen 
into this error, since in English and American works the limitation 
of the term compound is so exact, and the definition of complicated 
fractures so clearly given; the former implying the existence of an 
external wound communicating directly with the seat of fracture, 
and the latter that of some other injury materially modifying the 
case either locally or generally. Thus a fracture of the femur, with 
luxation of the hip-joint, is said to be complicated; so is a fracture 
of the leg, with delirium tremens ; but the term compound would not 
be applicable to either, unless there should be present the local con- 
dition above stated, in which case the injury would be a compound 
complicated fracture.] 

This simple statement shows how much that is arbitrary has been 
advanced upon this subject, and forewarns us of deficiencies which 
will be met with. In what circumstances, and how, do all these 
complications supervene ? What is their order of frequency ? Which 
sex, and what age, are most liable to them ? What fractures do they 
generally accompany? I am not now speaking of the prognosis or 
treatment ;' on these I shall hereafter dwell as much as possible. 

As far as I am enabled to state, from what I have seen, injury of 
the nervous trunks in cases of fracture is excessively rare; that of 
blood-vessels is a little more common. The complication of fracture 
with luxation is also quite rare, except in those cases in which a cer- 
tain fracture is an indispensable condition of a certain luxation, 
(which do not come within the scope of the present volume.) These 



80 A TEEATISE ON FRACTURES. 

cases excepted, of the 2358 fractures collected at the H6tel-Dieu, 
four only were accompanied by luxations, viz. : — 

1 fracture of the cervix humeri with luxation of the head of the bone. 

1 " " shaft of the humerus with luxation of the head of the bone. 

1 " " leg with luxation of the humerus. 

1 " " humerus with luxation of the femur. 

Next come fractures penetrating into joints, which are much more 
common; and lastly those attended with wounds of the skin, the 
most frequent of all complicated fractures. I would say, concerning 
these last, that we must distinguish three very different cases; (1) where 
the wound of the skin does not communicate with the fracture, and 
adds nothing to the gravity of the prognosis ; (2) where the wound 
does so communicate, but is caused by direct violence acting from 
without inward ; (3) where the wound is due to protrusion of one of 
the fragments, from within outward ; this can hardly occur but in 
indirect fractures, or when patients with direct fractures imprudently 
attempt to walk or stand on the limb. We shall return to this dis- 
tinction when on the subject of Prognosis. 

As to general complications, some have already been studied under 
the head of Predispositions; and there will be occasion to refer to 
them all under that of Terminations. 



ARTICLE III. 

GENERAL SEMEIOLOGY. 

In the preceding article, it was in some sort necessary to discuss 
the diagnosis of incomplete fractures, as far as their history was 
traced; what follows will therefore relate almost exclusively to com- 
plete fractures, single or multiple, simple or complicated. 

The phenomena to which these fractures give rise are numerous 
and varied. To study them nearly in the order in which they ap- 
pear, they are: cracking heard by the patient at the time of the 
accident, pain, loss of power in the limb, contusion of the skin, swell- 
ing, immediate or subsequent, preternatural mobility at the seat 
of injury, deformity from displacement of the fragments, and cre- 
pitation. 

(1.) Of the Cracking. — It is almost impossible for a bone to give 
way without a noise more or less clear and dry, which would seem 
sufficient to decide the diagnosis. But the sound of the blow or fall 
sustained, the surprise, 'the pain, the fright, the cries of the patient 
at the time, other noises, — in a word, so many causes hinder the per- 
ception of the crack, that it is heard by the patients in only a very 
small proportion of cases. They are especially apt to hear it when 



A TREATISE ON FRACTURES. 81 

the fracture occurs, we may say, without external violence, by sud- 
den muscular contraction; or perhaps when the bones, being weak- 
ened, are broken in bed by a very slight effort ; it sometimes even 
reaches the ears of the by-standers. It is certainly a valuable sign 
whenever obtained ; but we must not forget that the rupture of ten- 
dons, or of ligaments in cases of luxation, may also cause a clear 
noise, so much the more readily confounded with the crack of a 
fracture, since neither lasts more than an instant, and the ears hearing 
them are seldom expert. 

(2.) Pain. — Pain is a symptom very frequently complained of; 
I would not say always, for I have seen some cases of fracture, 
especially in rachitic persons, in which it was absent. There appear 
to be in this respect three classes; sometimes the pain is slight, or 
wanting; sometimes it is excessive, extorting violent screams from the 
patient, and persistent, or even increasing in severity ; lastly, in most 
cases it is quite acute at the moment of injury, but subsequently de- 
clines, at least unless it is excited anew by some motion. In the 
first class, the insignificance of the pain has seemed to me attributa- 
ble to rachitic softening of the bones, whether in children or in old 
persons; in the second, its severity is due to a morbid state not 
thoroughly understood, connected with inflammation of the periosteum 
or of the medullary tissue. Doubtless the sensibility, in some ex- 
aggerated and in others blunted, may have an important influence on 
the manifestation or even the perception of pain; or violent emotions, 
as on the field of battle, or disorder of the mind, as in insanity, may 
prevent the sensation of pain at the time of the injury; the suf- 
fering, however, may become very severe a few moments, hours, or 
days subsequently. 

The pain which is felt at first has, however, but slight value in the 
eyes of the surgeon; while that which is persistent, and especially that 
which on careful examination can be renewed or increased, may become 
very important in diagnosis. Often in fractures of one bone of the 
forearm or of the leg, the sound one serving to support the one injured, 
and the thickness of the muscles, or the swelling, masking any dis- 
placement or mobility, the pain alone gives a clue to the existing 
lesion, and warrants a diagnosis certainly not positive, but quite 
probable; or sometimes, calling the surgeon's attention, it puts him 
in the way of seeing other symptoms corroborative of its testimony. 
But there is one caution to be observed ; the pain may exist at several 
parts of the limb, especially in indirect fractures ; and it is of im- 
portance not to confound that caused by the blow and its resulting 
contusion, with that of the fracture itself. The degree of severity of 
the pain gives no light on this point; very often the contusion is 
much more painful than the fracture. But if the finger be passed 
slowly and carefully over the whole length of the suspected bone, 
unless it has been subjected directly to external violence, the ab- 

6 



82 A TREATISE ON FRACTURES. 

sence of all pain on pressure will prove its integrity; on the con- 
trary, the existence of pain more or less severe at a circumscribed 
spot would afford strong presumption of a fracture. In the opposite 
case, viz., if the external violence has acted on the bone, causing 
contusion and even inflammatory swelling, pressure usually induces 
pain toward the edge of the contusion or swelling ; this pain increases 
as the finger approaches the centre of the spot, but still there is a 
considerable space over which its intensity is nearly equable. If, 
however, there be a fracture, the instant the finger rests over it the 
pain is increased, violent as it may have been in the parts around; 
repeating the experiment, we may frequently succeed in exactly de- 
fining with the nail the seat of this sudden accession of pain, which 
disappears a few millimetres above and below. More than once, 
from this sign alone, I have ventured to diagnose a fracture, and to 
fix as the period necessary to a cure, that required for perfect con- 
solidation. In default of every other subsequent symptom, persist- 
ent pains, brought on by any attempt to use the limb, would prove 
the truth of my prophecy. 

It will be seen, nevertheless, that in such cases the diagnosis is 
open to some doubt, and that its precision will depend much on the tact 
and experience of the surgeon. It is therefore merely a probable 
diagnosis, and I freely admit that the chances of its accuracy are 
only about one in four or six. There still remain also cases in which 
the localisation of the pain is far less marked, and in which the pru- 
dent surgeon will make it a rule to wait, reserving his diagnosis for 
the time being, or giving none at all. 

(3.) Loss of Power in the Limb. — This symptom, which has been 
considered as of great significance in many fractures, is in reality of 
very little value. It is by no means rare to see patients with frac- 
ture of the fibula, walking, or with fracture of the radius or ulna, 
moving the hand and forearm ; moreover I have seen an old man 
with transverse fracture of the patella get up after his fall and walk, 
and another do the same with a fracture of the cervix femoris, the 
signs of which only appeared after he had been several days in bed. 
It is now well known that a fracture of the clavicle, even with dis- 
placement, may not prevent the patient from putting his hand to his 
head ; and I have assured myself that some patients having fracture 
of the cervix femoris, with shortening, could still flex the thigh and 
raise the heel from the bed. The interlocking of the serrations, or 
the impaction of the fragments, may partly account for these phe- 
nomena; and when the evident displacement of the fragments ex- 
cludes this mode of explanation, as in fractures of the clavicle, it has 
been supposed, with some reason, that these patients are enabled by 
the absence of pain to do what is impossible for others. 

It is certainly true that the majority of fractures induce a notable 
hindrance, or even an entire incapacity, of motion in the limb ; but 



A TREATISE ON FRACTURES. 83 

this depends on two very different causes, viz., the breaking of the 
bony levers, and the pain. To assign to each of these its due share 
in the effect produced, is often very difficult ; and, indeed, a simple 
contusion, without any fracture, may render motion more painful 
than an actual fracture would. I have several times seen falls on 
the hip prevent the patient from getting up, walking, or raising the 
heel; while the absence of every other symptom, and the rapidity 
of the cure, forbade any suspicion of fracture. The same thing 
occurs in the shoulder, as well as in other articulations. It is often 
very embarrassing to decide whether a difficulty of walking arises 
from a mere sprain, or from a latent fracture of the fibula. We see, 
then, how carefully we should weigh this symptom in forming a 
diagnosis. 

(4.) Contusion and Ecchymosis. — I intentionally put these two 
phenomena together, although in some respects they are unconnected ; 
contusion being strictly possible without ecchymosis, and ecchymosis 
often occurring entirely apart from any external contusion. But ordi- 
narily they are so closely associated that there is some advantage in 
treating of them together. 

Contusion, mainly recognisable by the bruising of the skin and 
abrasion of the epidermis, usually indicates pretty exactly the spot 
affected by any external violence, or the point of the surface struck 
in a fall. In direct fractures, it at once calls the surgeon's eye to 
the seat of fracture, and sometimes, in default of any other source 
of information, discovers to him the cause. Thus, in a fracture of 
the patella, or olecranon, a bruise of the skin over the bone would 
indicate a fall on the knee or elbow. On the other hand, we must 
observe a prudent distrust of some indications furnished by contu- 
sion. It is known that when it occurs on the head the point of injury 
often becomes the seat of a soft and compressible effusion of blood, 
while the extravasation into the surrounding tissue offers a resistance 
nearly as great as that of bone ; whence has often arisen the suspi- 
cion of a fracture with depression, none such in reality existing. I 
have made the same observation in regard to most of the superficial 
bones, — the tibia, patella, olecranon, even the infra-spinous por- 
tion of the scapula, — and shall take care to recur to these facts at 
the proper time and place. It may suffice for the present to point 
them out to the young surgeon. 

But often the integuments present no other trace of contusion 
than mere ecchymosis ; and when the fracture is indirect, ecchymosis 
may also occur in its neighborhood ; hence it is hard to say on what 
precise poicrt the force has fallen. Dupuytren, in some cases, at- 
tached great importance to this inquiry, and perhaps he sometimes 
displayed in it less than his usual sagacity. For instance, he thought, 
erroneously, that luxations of the humerus on the scapula were never 
caused by falls on the point of the shoulder ; and, on the other hand, 



84 A TREATISE ON FRACTURES. 

that falls on the elbow or wrist never fractured the cervix humeri. 
As a necessary consequence, in cases where the diagnosis lay between 
these two lesions, he examined with the greatest care whether the 
elbow or wrist showed any mark of contusion, any ecchymosis, any 
pain, or even a spot of dirt, indicating that one of these points had 
struck the ground ; and these slight indications would at once incline 
his mind to the idea of a luxation. Such, indeed, was the strength of 
his prepossession in this respect, that the patient might in vain de- 
clare, distinctly, firmly, and constantly, that he had fallen on the 
shoulder. Dupuytren evaded this testimony by alleging that the 
point struck was naturally thought to be that where most pain was felt. 
This assertion is doubtless true in many cases, and the fact should 
be carefully considered before the statement of a patient is blindly 
accepted. On the other hand, we should avoid the opposite extreme 
of always rejecting such evidence ; the degree of intelligence of the 
patient, the clearness of his story, and the consistency of its details, 
should be well weighed in coming to a decision. 

Moreover, just as the external violence causes sometimes contu- 
sion and bruising, sometimes a simple ecchymosis, and at other times 
leaves no trace at all, so also the ecchymoses from fracture vary in 
their seat, extent, and mode of appearance, while sometimes they 
are entirely wanting. Hence the difficulty of drawing any conclu- 
sions from them ; but their study will be better pursued when we 
come to each particular fracture. I shall confine myself here to the 
statement that they are in old people both more considerable and 
more lasting, often remaining even after consolidation ; they then 
extend themselves chiefly by reason of the mass of the extravasated 
blood, and we see them gradually invade the tissues more and more 
widely, spreading especially downward; sometimes blood effused 
very deeply only reaches the surface after some length of time. 
Fractures of the cervix humeri particularly have afforded me fine 
examples of this; and the knowledge of the mode of appearance, 
of the progress and of the decline of these ecchymoses, constitutes 
in such cases an essential element in forming a prognosis. 

(5.) Sivelling. — The swelling may be primary or secondary, and 
is owing to causes which, though very different, should be considered 
together on account of the similarity of their effects. At the instant 
of the fracture, there is often, but not always, an effusion of blood 
around the fragments, and an extravasation into the surrounding tis- 
sues, constituting strictly an internal ecchymosis, which, however, 
seldom betrays itself unless the integuments are laid open. When 
the fracture communicates with a superficial articulation, as, for in- 
stance, in a rupture of the patella, it is not uncommon to find the 
joint much augmented in volume by a large effusion of blood within 
the synovial membrane. 

A little later, the irritation developed maintains or increases the 



A TREATISE ON FRACTURES. 85 

swelling, but at the same time modifies its nature. The blood, 
partly absorbed, is replaced in the tissues by an effusion of plastic 
lymph ; in the articulations this accumulation of lymph constitutes 
a true hydarthrosis. This finally disappears without producing any 
further effect ; while to the inflammatory engorgement of the tissues 
usually succeeds a harder and more persistent swelling, which is the 
external callus. 

Primary or secondary, the swelling may quite as well be caused by 
a contusion as by a fracture ; and, so far from being of any use in 
diagnosis, it on the contrary seems rather to mask more closely what 
exists beneath it. This is usually the case ; and the practitioner 
should suspend his judgment until the swelling disappears. But it 
must be said that in some obscure cases the swelling may put us in 
the way of making a very probable diagnosis. Thus, when a mis- 
step has given rise to a lesion of the ankle, and the surgeon doubts 
whether it be a fracture of the fibula or a sprain, the existence of 
swelling above the malleolus would be a strong argument in favor of 
the former supposition. In some cases in which the knee has been 
attacked by violent inflammation as the effect of a fall, and the out- 
line of the patella can no longer be traced, the hydarthrosis has 
afforded me a valuable means of diagnosis. If we produce fluctua- 
tion, and perceive it clearly over the centre of the patella, there 
remains no doubt that the effusion is close beneath the skin, and 
hence that there is a transverse fracture of the patella, with separa- 
tion of the fragments. But this is perhaps the only case in which 
the swelling can serve to completely establish a diagnosis. 

(6.) Preternatural Mobility. — Here at last we come to a chief 
symptom, characteristic and nearly pathognomonic of fracture ; and 
I am astonished at the neglect it has sustained in most of our dog- 
matic treatises. Mobility seems so inevitable a consequence of the 
complete breaking of a bone, that at first sight nothing would seem 
so simple as to demonstrate it, or so easy as to interpret it; but 
here, as in everything, we find out difficulties as we study the subject 
more deeply. 

First, all fractures, even if complete, are not accompanied by a 
mobility as evident as would be desirable for making out the diagno- 
sis ; there are cases in which it can only be recognised by the aid of 
particular motions ; there are some in which it cannot be recognised 
at all. This is especially true of fractures by crushing, and of the 
ordinary fractures of thick bones, surrounded by numerous articu- 
lations. We cannot directly grasp either of the fragments ; to move 
them we must move the whole en masse, and we cannot determine 
whether the mobility resides in the suspected seat of fracture or in 
some neighboring joint. This difficulty is presented in the highest 
degree in fractures of the bodies of the vertebrae, and in those of the 
carpal and tarsal bones. It is met with also in fractures of long bones 



86 A TREATISE ON FRACTURES. 

occurring very close to joints, where one of the fragments cannot be 
seized, either from its small size or from its being buried in the mass 
of the tissues. Nothing is more difficult, for instance, than to say 
where the mobility resides in a suspected fracture of the cervix fe- 
moris, and in certain fractures of the lower end of the radius. After 
these come fractures of the diaphyses, involving only one bone of 
the leg or forearm, the sound bone acting as an inflexible splint for 
the other. And lastly, as I have already remarked in speaking of 
serrated fractures, even where there is but one bone in question there 
are cases in which the mobility is undetected from want of skill in 
the observer. 

As, indeed, the mobility has hitherto been hardly looked upon as 
more than an essential accessory to crepitation or displacement, its 
production has only been sought in order to elucidate one or the 
other of these phenomena. The fragments being left to themselves, 
the nature and extent of the displacement spoke so plainly, and the 
mobility also was so evident, that further examination was rendered 
useless. If, on the contrary, the fragments had remained nearly 
or quite in apposition, the disturbing of them was not dreamed of 
except to produce crepitation, by movements to be presently de- 
scribed, the object of which was to rub one fragment on the other ; 
and more than one evident fracture has been misconstrued because 
displacement was wanting and the nature of the mobility did not 
permit this rubbing and consequent crepitation. 

Now the means of demonstrating the mobility alone vary accord- 
ing to the seat and nature of the fracture. In the shaft of the hu- 
merus or of the femur, the upper fragment is to be fixed, and the 
knee or elbow carried in different directions ; the limb is then seen 
to be bent, the angle being at the seat of fracture. In the clavicle, 
the mere weight of the shoulder will produce this angle ; and if it 
has disappeared by the patient lying down, it may be reproduced by 
pushing the shoulder downward and inward. In fractures of the 
fibula, Dupuytren embraced the tibia with the four fingers of each 
hand, while with the two thumbs, stretched toward one another but 
not touching, he made pressure alternately upon two points of the 
fibula ; thus pushing toward the tibia one fragment or the other, and 
discovering the mobility. A similar manoeuvre will answer for frac- 
tures of the tibia, or of either bone of the forearm. But when the 
fracture is close to an articulation other data are necessary ; we must 
know in what motion the fragments best play one upon the other. 
Thus Desault conceived that in doubtful fractures of the cervix femo- 
ris the thigh should be rotated ; the arc of a circle, described by the 
great trochanter, should indicate by its extent whether this apophy- 
sis were still supported by the unbroken cervix, or moved merely by 
itself. M. Maisonneuve has discovered two valuable movements of 
this kind for testing certain fractures of the lower ends of the radius 



A TREATISE ON FRACTURES. 87 

and fibula. Thus in the former we may frequently detect a very 
sensible mobility by strongly bending the hand backward ; in the 
latter we may separate the fragments by carrying the point of the 
foot outward — results attainable in no other way. I limit myself 
here to these examples, having to return to this subject in connection 
with particular fractures. 

But in this examination we must not be misled by certain decep- 
tive appearances. I shall say nothing of rachitic bending of the 
bones, which is so rare an exception, that its very rarity is enough 
to put the surgeon on his guard. Pelletan has published the history 
of an osteo-sarcoma of the humerus, at the lower part of which the 
bone appeared movable and flexible; the autopsy showed that this 
was owing simply to softening, but circumstances more commonly 
met with may so much the more easily lead us into error. Dupuy- 
tren has warned us not to mistake for preternatural mobility the 
normal flexibility of the fibula, which is most remarkable at the 
middle of the bone, where it wants support. This mistake is more 
difficult to avoid in the ribs, which appear to bend under pressure, 
whereas they are only pressed inward; and which sometimes, in 
cases of senile rachitis especially, really bend under the fingers with- 
out any fracture. I shall never forget having diagnosed a fracture 
of the ribs in the axilla, because the bones seemed to me to yield at 
that point, when, as appeared from the autopsy, the real seat of injury 
was several centimetres in front of it. We should also avoid mis- 
taking the normal motion of a joint for the mobility of a fracture 
close to it. Lastly, I cannot too strongly warn young surgeons 
against an optical illusion not always easy to dispel. Suppose a 
fracture of the leg or forearm, with the skin deprived of its supple- 
ness, whether as the effect of age or of inflammation ; in endeavoring 
to produce angular deformity, we may find the skin to yield as if 
following the bending of the bones, and yet in spite of the appear- 
ance, the bone may be found to be intact. The deception is less 
likely to occur in recent fractures, where other symptoms come to 
the surgeon's assistance ; but in fractures arrived at the period of 
consolidation, when it is to be decided whether or not the callus is 
sufficiently firm, the want of mobility constitutes our only means of 
judging ; and I acknowledge that more than once this yielding of the 
skin has left me so much in doubt, that I have kept the limb at rest 
beyond the time strictly necessary, for fear of a fibrous and insuffi- 
cient callus. 

(7.) Deformity. — Whenever the fragments sensibly change their 
relative position, their displacement is betrayed by the change in the 
form of the limb; and often an experienced surgeon can at a glance 
divine the nature of the injury. It would however be unsafe to trust 
too much to first appearances ; the deformity may be due as well 
to a luxation as to a fracture; moreover, a severe contusion with 



88 A TREATISE ON FRACTURES. 

effusion of blood produces abnormal elevations which might easily be 
taken for either, or might, if a fracture were present at the same 
time, lead to error as to its seat and as to the nature of the dis- 
placement. 

An old man had fallen down on his side; an immense effusion 
extended over the hip and outer half of the thigh ; the shortening 
gave evidence of fracture ; but at first sight this seemed to occupy 
the shaft, while in reality it involved the neck, of the bone. 

Another had been violently struck on the back of the shoulder by a 
carriage-wheel, and the depression and deformity of the part were 
such as to make me suspect a luxation backward of the humerus. The 
shortening and crepitation indicated a fracture of the cervix ; but the 
deformity, which arose from a very large effusion of blood, so im- 
posed upon the eye, that a careful examination was necessary to 
convince me that it did not proceed from a dislocation. Such 
instances could be easily multiplied ; we will therefore return to real 
displacements, and state what are the means of verifying them. 

There are six varieties of displacement, some of which may exist 
alone, though usually several of them are combined. They are (1) 
transverse, or in the thickness of the bone ; (2) angular, or in its 
direction; (3) rotary, or in its circumference; (4) overlapping; (5) 
penetration; (6) lastly, direct separation of the fractured surfaces. 

Transverse displacement is always due to external violence, throw- 
ing one of the fragments forward, backward, or to one side ; it shows 
itself in various degrees, the fragment leaving its position by several 
millimetres, by one-half or two-thirds of its thickness, or entirely 
abandoning the opposed end of the other one, when overlapping be- 
comes inevitable, unless there be a parallel bone to prevent it. 
Overlapping occurs still more when the fracture is oblique; and in 
any fracture of a diaphysis, some degree of transverse displacement 
is essential to overlapping, which in its turn involves, with rare ex- 
ceptions, a certain amount of angular flexion of the bone or of the 
limb. 

This displacement is recognised by the projection of the fragments 
in opposite directions, or, if the bone can be examined only at one 
surface, by a greater or less inequality at the level of the fracture. 
This may be perceptible to the eye, but it is always important to 
confirm it with the finger ; we thus find out whether it is caused by 
an actual fragment, or merely simulated by splinters pushed out of 
place. When thus ascertained, it seems as if mistake were impossi- 
ble ; still there are numerous sources of error, as already mentioned. 
I do not allude to exostoses or to any other tumor of bone, although 
the surgeon should be always on his guard concerning them. But 
the normal inequalities of certain bones have been often mistaken for 
signs of fracture, as at the lower end of the fibula, at the upper end 
of the femur, at the elbow, etc. I shall again refer, at the proper 



A TREATISE ON FRACTURES. 89 

time and place, to these anatomical points ; but I shall here relate 
a curious case, setting forth a source of error hitherto unsuspected. 

An insane man, having sustained a severe fall, was brought into 
my wards. The left thigh was the seat of a considerable swelling ; 
but on close examination, I decided that no fracture existed, and 
treated the patient accordingly. Death ensued from other lesions, 
at the end of several weeks ; the thigh having nearly resumed its 
natural volume. "What was my amazement, on touching this thigh 
before the autopsy, at finding, three fingers'-breadths above the knee, 
a marked and firmly resisting prominence, exactly continuous with 
the anterior face of the bone ! I could only explain this phenome- 
non by the supposition of a fracture, the inferior fragment being dis- 
placed backward ; but why had I not detected it during life ? Dis- 
section cleared up everything; immediately above the capsule an 
effusion of blood had taken place in the cellular tissue, between the 
bone and the quadriceps ; this effusion, having become dry and hard, 
was at death projected upward, so that through the integuments no- 
thing distinguished it from the bone ; while lower down it was ab- 
ruptly terminated by the capsule, and hence the prominence which 
had so puzzled me. Otherwise the femur was completely sound. 

According to Boyer, transverse displacement pertained exclusively 
to transverse fractures, and hence nothing should have been easier 
than to remedy it. I have given the correct theory of these frac- 
tures, and I repeat that, even with a transverse direction, the great 
majority of fractures present serrations more or less considerable. 
Hence results the difficulty, sometimes invincible, of remedying a 
transverse displacement, however slight it may seem, and hence the 
necessity of strong extension for this purpose. At other times, also, 
it is kept up, or even augmented, by muscular action ; in oblique 
fractures of the leg, for instance, it is not rare to see the upper frag- 
ment of the tibia making an obstinate projection forward, and threat- 
ening to pierce the skin. Here the reduction is sometimes very dif- 
ficult — its maintenance still more so ; and we shall see, in the article 
concerning Treatment, to what formidable means we must resort in 
such cases. 

Angular displacement is frequently caused by external violence, 
as is especially manifest in cases of incomplete fracture ; but another 
and more permanent cause is the bad position of the trunk or of the 
limb, the weight of one of the fragments, or, lastly, the restlessness 
of the patient. Often, in fractures of the femur, the limb being 
placed in a proper apparatus, the pelvis inclines too much to the 
sound side, drawing with it the upper fragment, the lower end of 
which then projects outward. I have seen the same result brought 
about directly by the patient, in certain cases where the limb was 
completely enveloped in a bandage up to the groin. The perspira- 
tion retained by this induced an itching at the upper and inner part 



90 A TREATISE ON FRACTURES. 

of the thigh, making the patient scratch himself; to do which he 
was obliged to pass his fingers between the bandage and the skin, 
pushing out the fragments, already at an angle with each other. The 
weight of the limb is especially to be dreaded in fractures of both 
bones of the leg, in which the heel, being badly supported, gets lower 
than the rest of the limb, inevitably causing an angular projection 
forward at the seat of fracture. 

Lastly, muscular action sometimes constitutes a cause of angular 
displacement, when the fragments are held together by their serra- 
tions, the contracted muscles tending to approximate their points 
of attachment. But even when due to this cause, this displacement 
is usually easy to overcome, unless on account of the depth of the 
fracture or the small size of one of the fragments. 

Rotary displacement, or that in the circumference of the bone, 
takes place when one fragment executes a movement of rotation, 
the other remaining stationary ; the former being generally the in- 
ferior. Sometimes this displacement is owing to external violence, 
or to motions impressed on the limb after the fracture ; sometimes, 
perhaps, to muscular action ; more frequently to the weight of the 
limb, favored by an improper apparatus. The type of this displace- 
ment is manifested in fractures of the neck and of the body of the 
femur ; and in giving an account of these, reference will be made to 
all the opinions entertained on this subject. 

Overlapping is sometimes induced by the same cause as the frac- 
ture itself, as when a fall on the feet breaks the femur obliquely, 
bringing one of the fragments out through the skin ; sometimes by 
the mere weight of the body resting upon a bone already broken. 
In this manner Pare, when his leg was fractured by the kick of a 
horse, in stepping back to escape another kick, caused the fragments 
to overlap and project through the skin. But oftener muscular action 
is here the essential cause, whether at the time of the injury, or 
during the course of the treatment ; it is at least the most trouble- 
some difficulty to overcome. When this acts alone, it always draws 
up the lower and less weighty fragment toward the upper, made im- 
movable by the weight of the body. But this has been improperly 
stated as the general rule ; and practitioners should bear in mind that 
often the body, sliding down in the bed by its own weight and by its 
inclined position, pushes the upper fragment against the lower. Such 
is especially the case in fractures of the femur. 

Displacement by 'penetration belongs somewhat to overlapping, its 
essential effect being to shorten the bone ; but it differs from it in 
generally occurring without transverse displacement. It takes place 
only in indirect fractures of the spongy extremities of the long bones, 
and is always caused by external violence, at the same time with the 
fracture itself. Usually, then, it is the diaphysis which buries itself 
in the cancellous tissue of the epiphyseal portion. Fractures of the 



A TREATISE ON FRACTURES. 91 

cervix humeri (Figs. 29, 30, 31, and 32,) and of the radius (Fig. 
54,) offer quite frequent examples of this. It seems as if the con- 
trary sometimes occurred in the cervix femoris, where the epiphyseal 
portion buries itself in the spongy tissue of the other fragment (Figs. 
69 and 70 ;) and there are in the Muse'e Dupuytren several speci- 
mens of recent fractures, in which the penetration has actually taken 
place without crushing of the great trochanter. But these cases are 
very rare ; and after consolidation has occurred it is perhaps impos- 
sible, as in the two instances cited, to determine whether there has 
been crushing or mere impaction. The difference between these two 
states is far more marked in the cervix humeri; and in strictness, 
crushing cannot occur without impaction of the fragments ; but this 
kind of displacement may also take place in simple fractures, like 
most of those of the lower end of the radius. 

In the majority of cases the penetration is more considerable on 
one side than on the other, so that it is almost always accompanied 
by angular displacement. In fractures of the radius, the angle is 
generally open posteriorly, salient anteriorly ; in fractures of the 
neck of the humerus and of the femur, the angle of union of the 
head with the diaphysis diminishes in aperture in proportion as the 
penetration is greater. Moreover, it must not be thought that the 
impaction is as marked in the beginning as after the occurrence of 
consolidation; in examining, for instance, Fig. 59, one would sup- 
pose that the diaphysis was buried to a depth of more than two cen- 
timetres in the spongy tissue of the epiphysis. It is not so ; all the 
triangular production of spongy tissue, joining one portion to the 
other, is formed of callus ; and Fig. 57 gives an exact representa- 
tion of the primitive displacement, before the callus had filled up the 
angle left between the two fragments. I would add, lastly, that the 
fragments are not crowded together and adherent to one another, as 
in true crushing. It is essentially the consolidation which produces 
the appearance of so marked an impaction. 

Finally, displacement by separation, long regarded as exclusively 
belonging to fractures of the patella, olecranon, and os calcis, and, 
as in those cases, solitary, and not easily combined with any other, 
is met with also in certain fractures of the articular extremities ; as, 
for instance, in those of the fibula, where it is an epiphenomenon of 
rotary displacement. It is especially common in transverse fractures 
of the patella ; and then it is essentially due to muscular action, 
although a bad position of the limb may greatly increase it. 

To sum up, we see that the causes of all these displacements may 
be divided into four kinds : the exterior cause of fracture ; a bad 
position, enough of itself to disarrange the fragments, and aided by 
the weight of the body or of the limb ; external forces acting on the 
broken bone, as when the patient, wilfully or while delirious, himself 
puts the apparatus out of order ; and lastly, muscular action. The 



92 A TREATISE ON FRACTURES. 

first cause acts but for a moment, and its effects can always be reme- 
died except in cases of loss of substance by comminution or crush- 
ing of the bone. The second is more permanent, and demands 
careful watching during the whole period of treatment; but this 
also is an accident, as it were passive, and can nearly always be 
avoided or corrected. The third requires likewise some care in indo- 
cile subjects; in insane patients I have more than once had to resort 
to forcible restraint ; but these exceptional cases do not involve the 
same degree of responsibility to the surgeon as others do. There 
remains the fourth, unceasingly and actively counteracting our en- 
deavors, always to be dreaded, and sometimes invincible — muscular 
action. It is therefore essential to determine with the utmost pos- 
sible exactness what is its nature, and under what conditions it comes 
in play, in order to use the necessary means of combating it. 

The muscles act on the fragments of a broken bone by momentary 
contractions, or by incessant tension. 

Their contraction is voluntary, semi- voluntary, or entirely involun- 
tary. Voluntary contractions are seldom met with but in insane or 
completely unmanageable patients ; it is, however, well to forewarn 
such patients of the danger resulting, in order more easily to per- 
suade them to keep the limb at rest. There is, in some fractures, a 
period when one may easily study the effects of voluntary contrac- 
tion ; I allude to those instances, happily rare, in which the frag- 
ments remain ununited and independent of one another ; these will 
be again discussed in speaking of Terminations. 

Semi- voluntary contraction is generally brought on by attempts 
to elongate the limb, which of course stretch the muscles. The pain 
thus induced appears to impel the muscles to resistance by contrac- 
tion, although the influence of the will is made manifest by the effect 
of diverting the mind; by distracting the attention of the patient, 
and fixing it clearly and steadily on some other object, we greatly 
lessen, or even destroy the muscular resistance. Dupuytren attached 
great importance to this means in the reduction of luxations ; and 
perhaps it is too much neglected in treating fractures. 

Lastly, the irritation is sometimes so high, and the pain so intense, 
that the muscles are affected with convulsive contractions, recurring 
at intervals ; these have received the name of subsultus. It is vain 
to seek to overcome this action by main force ; the surest plan is to 
combat the irritation and wait for its subsidence. 

The contraction assumes, then, two forms : sometimes it is volun- 
tary or physiological, and may be obviated by diverting the patient's 
attention, by appealing to his self-command, or finally, by the em- 
ployment, if needful, of a superior force ; sometimes it is involuntary 
or spasmodic, depending on an irritation which must be subdued first 
of all. 

The same distinction may be made in regard to retraction, [or 



A TREATISE ON FRACTURES. 93 

steady tension,] except that this is always involuntary. Sometimes 
it is purely physiological, and is then limited in extent and easy to 
overcome ; sometimes the irritation, rising to a pathological state, 
exceeds all bounds, causes a shortening twice or three times as great 
as natural, and resists with incredible force any efforts to overcome 
it ; such efforts even increase it, by exciting the fibres to convulsive 
contraction. I have particularly examined these two varieties of 
retraction in my Anatomie Chirurgicale, and will not here repeat 
the details there presented. I would, however, again say that any 
muscular action, of either kind, can only be combated to advantage 
when reduced to the limits of a physiological state ; and that when 
the irritation rises to a pathological degree, we must wait for its 
subsidence. 

This will be further practically applied in the article on Treat- 
ment ; let us now examine how far displacements are due to mus- 
cular action. The question will repay the trouble of its discus- 
sion, so much the more that the solution at present received seems 
to me at variance with the results of strict observation. 

It is generally stated that the majority of displacements are pro- 
duced by the muscles ; so that, a fracture occupying a given point in 
any bone, according to this theory we may foretell the displacement 
which will ensue. So far has this been carried that an English wri- 
ter, Hind, wishing to show by a series of plates the causes of dis- 
placement in fractures of the extremities, could find no better plan 
than to delineate the bones and muscles of a dead body, making the 
latter pull on the former according to the seat of fracture ;* never 
dreaming that the Hunterian Museum, some paces from his amphi- 
theatre, would have utterly contradicted in advance his fantastic re- 
presentations. I have severely criticised, in my Anatomie Qhirur- 
gicale, these false applications of pure anatomy to pathology; and 
without referring the reader to our public museums, my drawings 
will suffice to show all that is requisite, and all that is to be dreaded. 

Xo, in the great majority of cases, the course of things is not as 
is stated by anatomists ; the muscles alone have not so much power 
as is claimed for them, and they meet with many obstacles which 
they cannot overcome. The impulse given by the cause of fracture, 
the direction of the fracture, the impaction of the serrations, the re- 
sistance of the periosteum, and other soft parts, the position and the 
weight of the limb, mainly determine the nature and extent of the 
displacements ; only one of these latter can be under the almost 
isolated influence of muscular action; I allude to overlapping. But 
it must be remembered, that then it is not one or two muscles which 
act on the fragments, but the whole muscular mass surrounding the 

* G. W. Hind, A Series of Tvjenty Platen, Illustrating the Causes of Dis- 
placement in the various Fractures of the Bones of the Extremities ; lith. in 
folio, London, 1835 ; analysed in the Medico- Chirurgical Review, Oct., 1835. 



94 A TREATISE ON FRACTURES. 

bone ; and that the overlapping, by burying still more the broken 
ends in the flesh, causes almost always an irritation raising the con- 
traction to a pathological degree. On the contrary, when a frag- 
ment is pulled upon by only one or two muscles, we may say that it 
yields to their action only as far as it is entirely free, and unop- 
posed either by the direction of the fracture, by the resistance of the 
periosteum or of other muscles, or by the weight of the limb. I have 
had drawn (Fig. 33) a magnificent specimen of fracture of the 
cervix humeri, in which the upper fragment was brought into com- 
plete abduction by the supra-spinatus muscle ; but then the violence 
of the blow had driven the lower fragment far into the axilla, de- 
stroying all connection, by means of the periosteum, with the upper 
one. But in this very sort of fracture, if the fragments remain ever 
so slightly in contact, if the periosteum be not entirely torn asunder, 
the displacement does not occur; and this is far more frequently 
the case. 

From these considerations result two consequences of great prac- 
tical importance, viz., (1) that every displacement, except overlap- 
ping, may be reduced and obviated, if only the fragments afford a 
sufficient hold ; (2) that overlapping is the most stubborn of all. It 
is a disagreeable truth, generally too much kept out of sight by the 
classical authors, that overlapping is so stubborn as to baffle the 
efforts of art to overcome it, in the immense majority of cases. 

(8.) Crepitation is the sound produced by friction of one fractured 
end upon the other. According to this simple definition, it may be 
easily seen that crepitation will fail to occur in many cases. If, for 
example, the surfaces are so closely held in contact by their serra- 
tions and by the integrity of the periosteum, that their rubbing is 
hindered, crepitation will not take place ; as happens in many ser- 
rated fractures without displacement. If, on the other hand, the 
surfaces are so separated that they cannot be made to approach one 
another, crepitation will again be wanting; this occurs in fractures 
with very marked overlapping, when the fragments lie side by side ; 
or when the contact is between the side of one fragment and the 
fractured surface of the other, as in intra-capsular fractures of the 
cervix femoris. I may just allude to cases in which a mass of blood- 
clot, a bit of muscle, or any other body, is interposed between the 
two fragments, hindering their direct contact. But to all these ex- 
ceptions must be added fractures by crushing, which rarely give an 
appreciable crepitus; fractures with penetration, of which the same 
may be said; fractures of one of the two bones of a limb, etc. ; and 
it may hence be seen how inconstant and how fallible this symptom 
is in a large number of cases. 

On the other hand, the more numerous and easy the rubbings of 
the fragments, the clearer and more distinct is the crepitation. Thus 
in splintered and comminuted fractures, the least movement im- 



A TREATISE ON FRACTURES. 95 

pressed on the part, the least pressure at the seat of fracture, will 
cause a sound loud enough to be heard by the surgeon, the patient, 
and the by-standers. Generally in simple fractures neither pressure 
nor irregular moving of the limb will suffice; it is necessary to make 
certain motions, according to known rules. Thus one fragment must 
be fixed, and motion given to the other, or both must be grasped and 
moved upon one another in different directions. If the size of the 
limb permit, the surgeon takes hold of it with his two hands ; if not, 
the upper fragment should be fixed by an assistant, the surgeon 
merely managing the lower one. It is well then to place the fingers 
of the left hand over the seat of fracture ; I have even thought proper 
sometimes to commit the entire motion to assistants, in order with 
both hands to examine the suspected injury. 

It is generally recommended to move the fragments laterally ; but 
we should bear in mind that frequently this manoeuvre fails, and 
others succeed better. Thus in fracture of the cervix humeri, rota- 
tion alternately inward and outward will be the surest plan ; in frac- 
ture of the neck of the femur, flexion and extension, adduction and 
abduction, likewise made alternately, are preferable. In some cases, 
if the surfaces are too closely pressed against one another, they will 
not have sufficient play, and must be separated somewhat by proper 
traction. In other cases they are too far apart, as in fractures of 
the patella ; and then they must be brought together. 

AYith all these precautions, it frequently happens, first, that cre- 
pitation is absolutely wanting, as under the circumstances before 
mentioned; then, in more favorable cases, it may be slight, momen- 
tary, doubtful ; again the surgeon may be uncertain whether the cre- 
pitation is really osseous, or only an emphysematous crackling, a 
rubbing of the tendons in a congested sheath,, or lastly the click of a 
joint, stiffened, inflamed, or deprived of its cartilage. Boyer has 
declared that an experienced surgeon can easily avoid these errors ; 
and in fact, bony crepitation, when clear and distinct, has character- 
istics distinguishing it perfectly, especially from the crackling of 
tendons or from emphysema. But when it is feeble and obscure, 
and needs to be diagnosed from the click of a joint, there is much 
more difficulty; for my own part, I have been in doubt several times, 
and several times have seen Dupuytren himself hesitate. M. Lis- 
franc conceived that the stethoscope would clear up everything, and 
even published a special memoir on this subject.* But surgeons 
know well that crepitation reveals itself rather to the hand than to 
the ear; or rather that it is transmitted from the hand to the ear 
more certainly than in any other way. As for myself, I have never 
heard by means of the stethoscope crepitation which I had not other- 

* Lisfranc, Mtmoire sur de Nouv. Applic. de Stethoscope. Paris, 1823 ; re- 
produced in the Clinique Chirurgicale of the same author, tome i, p. 51. 



96 A TREATISE ON FRACTURES. 

wise perceived; and although I would not prevent its use by others, 
I have myself abandoned it. 

Lastly, there are cases in which crepitation is remarkably clear at 
one moment, at another entirely wanting; the best planned move- 
ments do not elicit it, while those made at hap-hazard succeed; 
moreover, the same movement which produces it at one instant will 
fail the next. It is frequently impossible to decide where it occurs ; 
thus for example, I once attributed to the fibula a crepitation of this 
kind, which really belonged to the calcaneum ; and many such mis- 
takes are made. I have but one remark to add here ; it is that the 
crepitus is not equally perceptible at all periods of a fracture; 
its detection being frequently impossible until the inflammatory 
swelling subsides, and equally so after the callus begins to be or- 
ganised. 



ARTICLE IV. 

COURSE AND TERMINATIONS. 

This portion of the history of fractures comprehends the study 
both of the exterior phenomena, and of the more obscure processes 
going on within the tissues. 

§ I. — Of the Exterior Phenomena. 

We have seen in the preceeding article what were the most usual 
symptoms of fracture, immediately upon its occurrence ; we must now 
follow its subsequent stages, whether of improvement or of aggrava- 
tion. We are concerned at present only with simple fractures ; the 
other forms are better studied by themselves. 

The simplest fractures are frequently unaccompanied by con- 
tusion or great pain; they cause no inflammatory swelling; in a 
word, the patient is made aware of the injury only by the loss of 
firmness of the limb, and by the pain felt from certain movements. 
By perfect rest, maintained during a time varying in different cases 
from fifteen days to a month or six weeks, reunion silently occurs, 
and the fracture leaves no trace; in order to this it is manifestly 
requisite that the fragments should remain in exact apposition. 

Even if the broken ends are displaced, it may still happen that no 
inflammation supervenes. During a period varying according to the 
age of the person, and the bone affected, the fragments seem to re- 
main free, and as it were floating among the muscles; after this they 
gradually lose their mobility ; they are now felt to be enveloped in a 
sort of tumor, not involving the more superficial tissues, slightly 
sensitive to pressure, but without either redness of the skin or ge- 



A TREATISE ON FRACTURES. 97 

neral reaction ; the patient eats, drinks, and sleeps as usual ; the in- 
flammation cannot be said to exceed that in the other case. This 
tumor gradually hardens, finally assuming an osseous consistency; 
it is now impossible to produce the least motion of the fragments ; 
consolidation is effected; but there will always be a double trace of 
the fracture, to wit, the abnormal projection of the fragments, and 
the prominence of the osseous tumor enveloping them. 

It is by no means always the case that things go on so favorably. 
"Whether the fracture be with or without displacement, but much 
oftener in the former case, it is from the beginning attended by no- 
table swelling of the surrounding soft parts; this is due at first to 
effusion of blood, but is maintained or even increased by actual in- 
flammation. Sometimes, if the bone be deeply placed, the inflam- 
mation will not involve the skin, this retaining its natural color; but 
the limb is swollen, tender, hot and painful; the patient feels it con- 
tinually throbbing ; and to these local symptoms there is often added 
a general reaction, an actual traumatic fever, with thirst, loss of ap- 
petite and sleep, and increased action of the heart. If the bone be 
more superficial, the skin itself reddens, swells, and is seen by the 
most inexperienced eye to be inflamed. This inflammation sometimes 
goes off in two or three days ; sometimes it lasts till the fifteenth day, 
but generally it has disappeared by the seventh. Then the fever 
subsides, the redness and swelling abate; but the tumor around the 
fragments is somewhat larger than in the two preceding cases. This 
tumor gradually grows firmer, and may at the same time be felt to 
diminish, and to involve to a less degree the surrounding tissues; 
but it never entirely disappears ; for though it is true that in fractures 
which are kept very accurately in apposition, one cannot detect 
during life the slight thickening around the broken ends, still upon 
dissection it may easily be shown by sawing open or merely by feeling 
the bone. 

In comparing these two different modes of accomplishing the same 
object, — the consolidation of the fracture, — it must be remembered 
that in divisions of the bones, as in those of the soft parts, reunion 
may take place without inflammation, by a simple reparative process; 
while at other times there is added an actual inflammatory condition, 
which cannot safely pass beyond the adhesive stage. These are the 
ideas of John Hunter, and I accept them without reservation. 

The period requisite for complete consolidation should be first 
studied, and afterwards that of each stage, above described, of the 
reparative process. The former varies with the age, with the bone 
involved, with the character of the fracture. All that can be said 
on this point is that in very early infancy, less time by one-half is 
required than in adult age : it has been asserted that union is much 
more tardy in old age, but I must say that this is not confirmed by 
careful observations of the fractures in old people treated by me at 

7 



98 A TREATISE ON FRACTURES. 

Bicetrc. Nor can I discover any difference depending on sex, or 
any referable to the seasons. I speak now of fractures comparable 
with one another, that is, occurring in the same bones, and under the 
same conditions ; a fracture with displacement cannot be so solidly 
united in the same time, as one kept in perfect apposition, and frac- 
ture of any one bone is sooner united when at one end than when in 
the shaft. 

In this respect different bones present notable differences. Usually 
the bones of the lower extremities are more slowly consolidated than 
those of the upper, and these latter more slowly than those of the 
face. Doubtless, greater firmness is requisite in those which have 
the weight of the body to support; and especially in those which 
alone form the skeleton of the limb, as the femur and the humerus. 
Doubtless also the size of the bone should be taken into the account; 
thus it is not strange that the tibia should require more time to unite 
than the humerus. But aside from these considerations, I have been 
led to infer, from what I have seen in both the living and the dead 
body, that consolidation actually takes place more slowly in the 
bones mentioned; this has been most conclusively proved to me by 
the comparison of extra -capsular fractures of the humerus and femur, 
of the lower end of the radius and of the calcaneum. 

Moreover, it should be added that the exact period requisite for 
consolidation, even fixing all the conditions of the patient and of the 
fracture, cannot be assigned; and that for safety to the surgeon and 
his patient, a longer time should always be allowed than is strictly 
necessary. This explains the apparent contradictions of practitioners, 
some demanding as much as two or three months for the consolida- 
tion of fractures which others declare to be cured at the end of six 
or seven weeks ; and sometimes surgeons have erred from timidity, 
sometimes from temerity. I shall carefully discuss, in treating of 
each fracture, the contradictory opinions, and seek to give the most 
precise results of experience. 

As to the other question of the distinction of periods in the repara- 
tive process, it seems to me that there may be marked out three 
such, each comprising one-third of the time requisite for complete 
consolidation. The first is entirely preparatory; nature is occupied 
in absorbing the ecchymosis, lowering the inflammation, and secret- 
ing matters necessary to union. In the second, these materials are 
organized, forming around the broken ends a gradually solidifying 
envelope, in which, however, the process of ossification cannot yet be 
clearly traced. The third is entirely devoted to this latter process, 
subsequent to which I do not believe that there is any other; the 
application of this remark will be seen when I come to speak of the 
theories put forth concerning the development of callus. 

But all is not completed with the consolidation of the fracture; 
other phenomena arrest our attention or call for our interference. 



A TREATISE ON FRACTURES. 99 

The limb is more or less wasted, from disuse; the skin is dry, 
wrinkled and scaly. The muscles fulfil their functions but feebly 
at first, the movements are vacillating, and the patient instinctively 
feeling the weakness of the limb, does not for some time trust him- 
self to it. I am not now speaking of those grave cases in which the 
muscles are encroached upon by the callus, and have irreparably lost 
their power. If the horizontal position has been long maintained, 
the limb swells and reddens if allowed to hang down. Sometimes, 
also, whether from bad treatment, or as the result of some complica- 
tion, there remains in the cellular tissue an oedema more or less firm 
and persistent. 

Until recently, no attention was paid to the state of the nails, in 
the growth of which Dr. Guenther claims to have discovered certain 
phenomena which constitute a certain and therefore valuable sign of 
the consolidation of the bone. He was led to this discovery by ac- 
cident ; a young man, with a very oblique comminuted fracture of 
the right leg, remarked that the nails on the right foot did not grow 
like those on the left; he informed the doctor, who thenceforward 
examined the nails daily with the greatest care; by the fiftieth day 
the nail of the little toe was found to begin to increase ; a little later, 
those of the three next toes, and finally, after some weeks, the nail 
of the great toe. With this growth came the sensation of firmness 
in the limb, and consolidation was actually complete. After 1832, 
the date of this observation, the doctor claims to have seen many 
similar cases, and he concludes that in fractures of the extremities 
the arrest of growth of the nails is a constant phenomenon, persisting 
until union is definitively established.* 

I first endeavored to substantiate this statement in two patients 
affected with fracture of the humerus and of the radius, without dis- 
placement; consolidation was only begun, but the nails were alike 
on either side. I attempted a more strict experiment on an adult 
patient who had an oblique fracture of the humerus, with overlapping 
and active inflammation. He was directed not to trim his nails, and 
these were most carefully measured with a compass on the second 
day, on the twenty-first day, and lastly on the thirty-seventh, some 
days before the completion of consolidation. The nails grew alike 
on the fingers of the injured and sound sides; and Doctor Guenther 
was certainly the dupe either of his patient or of his own imagi- 
nation, f 

But we must give much more serious attention to the effects pro- 
duced on the joints, whether by the fractures themselves or by their 
treatment. Perhaps there is not a single fracture which can be con- 
sidered cured merely because consolidation is complete; for, if by 

* Gazette des Hofntaux, Nov. 24, 1842. # 

f See my Journal de Chirurgie, Feb., 1842. 



100 A TREATISE ON FRACTURES. 

the word cure we mean the restoration of the functions to their normal 
state, the fact is that the stiffening of the joints hinders the functions 
of the limb for a much longer time than is required to unite the 
bone. I have seen fractures of the neck of the humerus, treated by 
myself with the utmost care, prevent the return of the arm to its 
functions for two or three months. I have seen a patient under the 
care of Boyer, who could not walk freely for a year after being dis- 
missed as cured of a fracture. I have seen old persons, discharged 
from the hospitals as cured of fractures of the cervix femoris, unable 
to go without their crutches, four or even seven years afterwards; I 
have seen one who, twenty years after such a fracture, had not yet 
recovered the free flexion of the knee;* and I shall have to mention 
similar cases in connection with nearly all fractures. Stiffening of 
the joints is then the last consequence, the most persistent of the 
consecutive phenomena of these lesions ; and it is not till after its 
disappearance that the limb entirely resumes its normal functions. 

This result, however, cannot be attained at all except in fractures 
with little or no displacement ; slightly marked as may be the over- 
lapping or any other form of derangement of the bone, the patient 
is condemned to keep all his life annoying reminders of his fracture, 
such as deformity, impaired function, weakness, or even loss of cer- 
tain motions, in the limb. 

The deformity varies in form and degree, according to the nature 
and extent of the displacement. Sometimes it is an unpleasant pro- 
minence, as in the majority of fractures of the clavicle; sometimes 
an unsightly enlargement of the limb, as in some fractures of the 
humerus ; or an angle in a limb which should be straight, as the leg 
or thigh; or a deformity about a joint, as in fracture at the elbow. 
Shortening is at once a deformity and a cause of diminution or loss 
of power; in the lower extremity, it leads to an almost inevitable 
limp ; in the forearm, it hinders pronation and supination ; we shall 
see that even in the clavicle, overlapping is more injurious than is 
usually stated, from its effect on the freedom of motion of the shoulder. 
At the same time, power is lost ; no man whose leg is shortened can 
carry so heavy a burden as before; and lastly, as examples of abso- 
lute loss of some movements and even of all of the important func- 
tions of the limb, we may cite the consolidation of both bones of the 
forearm, [one mass of callus being formed,] and the occurrence of 
union with the fragment at a nearly right angle, in the leg or femur ; 
of which specimens may be seen in almost all extensive museums. 
Deplorable consequences these, whether of the fracture, of the ab- 
sence of treatment, or even of the treatment itself; but which, aris- 

* Malgaigne, Be quelques dangers du trait, ord. des fractures du col du 
fdmur; Bulled de The'rapeutique, Aug., 1841. 



A TREATISE ON FRACTURES. 101 

ing from whatever cause, constitute an essential part of the history 
of fractures, and a part far too much neglected. 

It would be well if this were the worst termination we had to fear. 
But even in the simplest fractures it often happens that there is no 
consolidation ; it may be that the treatment is inefficient, the surgeon 
giving up in despair, as in intra-capsular fractures of the femur, and 
in the majority of fractures of the patella; he may have been igno- 
rant or negligent ; or lastly there may have been, spite of the wisest 
precautions, a general or local disposition preventing osseous union, 
and leaving the patient only a weak and powerless limb, a broken 
lever in place of a firm one. I have seen these defects of consolida- 
tion in all degrees, in the living subject; in a patient affected with 
fracture of the lower fourth of the femur, the fragments, although 
movable, were so interlocked that of thirty-six acupuncture needles 
successively introduced, not one entered between them. I have on 
the other hand seen in a little girl, two years old, an ununited frac- 
ture of the condyles of the humerus, in which the fragments were 
separated more than a finger 's-breadth; and lastly I have recorded 
the observation, at Bicetre, of an old fracture at the middle of the 
humerus, the upper fragment of which could be raised horizontally 
by the deltoid, while the other hung freely at its extremity; by 
pinching the arm in the interspace, the skin of the two sides could 
be so closely brought together as to leave between them only about 
a finger 's-breadth, within which the brachial artery could be felt 
beating. 

Finally, it sometimes happens that a fracture, without any lesion 
of the integuments, is attended by suppurative inflammation, giving 
rise to immense abscesses and sinuses; or perhaps that an obstinate 
fragment, bearing against the skin, at last causes gangrene, thus ad- 
mitting the air to the seat of fracture; or even that from the very 
first, owing to the original violence, the skin is torn so as to expose 
the fracture ; and in all these cases we have not only to fear exfolia- 
tion of the bones, slow formation of callus, or necrosis of the frag- 
ments, but even worse accidents than these; such as stripping up of 
the skin and muscles ; phlebitis, perhaps requiring the sacrifice of the 
limb; or still graver symptoms, such as extensive phlegmonous in- 
flammation, intense fever, nervous delirium, tetanus, seriously en- 
dangering the patient's life; and lastly purulent infection, which is 
almost invariably fatal. 

AVe have not to trace the history of all these complications, which 
are only so many new disorders superadded to the fracture, this latter 
being strictly only the exciting cause; still it belongs to our subject 
to study at least the mode in which the callus is formed in these diffi- 
cult cases, as well as to show the reciprocal influences of the fracture 
and its complications ; for this concerns both the prognosis and the 
treatment. But we have not yet come to this; the external pheno- 



102 A TREATISE ON FRACTURES. 

mena which have been thus rapidly sketched have their causes and 
their rationale, which remain to be explained ; there is first the whole 
theory of callus, comprising two different subjects; that of its origin, 
whether in simple or compound fractures, and that of its transforma- 
tions ; there is then the theory of consecutive false anchyloses ; and 
lastly there are the causes of non-union, or the theory of false joint. 
We shall therefore arrange under four separate heads what remains to 
be said concerning the terminations. 

§ II. — Of the Formation of the Callus. 

Perhaps no other question in surgical pathology has been so often 
agitated, or so variously solved, as that of the formation of callus. 
The oldest idea is that which attributes it to the marrow, considered 
as the aliment or nutritious juice of the bone; medulla ossis alimen- 
tum, ideo callo firmatur. Galen, rejecting what this theory had too 
much assumed, regarded the callus as due to the excess of nutritious 
juice brought to the bones by the blood, over that sent to all other 
parts ; and these two views, the Hippocratian and the Galenian, had 
each its supporters until the beginning of the seventeenth century; 
at which time, a very animated controversy arising on this point be- 
tween Lanay and Jacques de Marque, the latter demonstrated logically 
that the marrow could not of itself furnish the materials for the callus.* 
From that time, Galen's theory obtained the preference, and we find 
it still in favor late in the eighteenth century, even when experiment 
would seem to have contradicted it. 

In 1684, Antoine de Heide, studying the callus in frogs, arrived at 
the quite novel conclusion that it was the result of coagulation of the 
blood effused around the fragments. In 1741, Duhamel attributed 
it to the ossification of the periosteum and of the medullary tissue; 
Haller and Dethleef, followed by Troja, placed beyond doubt the 
secretion of an ossifiable plastic lymph, which formed part also of the 
theory of Galen ; Bordenave, agreeing with them concerning the effu- 
sion of this lymph, concluded nevertheless that the bone became re- 
united by means of its vesicular tissue; Camper believed that the 
interior osseous fibres of each fragment were so prolonged as to meet 
one another ; J. Hunter revived, in a somewhat more general form, 
the hypothesis of Antoine de Heide ; Manne and Bichat imagined 
the callus formed by granulations; and lastly M. Breschet has 
united the two principal theories, ascribing the origin of callus to 
blood and lymph combined, f 

* Hippocrates, De Alimento ; Cassii Iatrosophistse Questiones, qucest, 58 ; 
Galeni, Comm. 1 in libro de Fracturis ; Comm. I de Articulis ; Methodi 
Med., lib. vi, cap. v ; J de Marque, Paradoxe ou Traicti MSdullaire, Paris, 
1609, 12mo. 

t Antoine de Heide, Anat. mytuli; subjecta est cent. Obs. Med., obs. 57 ; 



A TREATISE ON FRACTURES. 103 

We say then at once that the theory of granulations, however spe- 
cious as regards fractures exposed to the air, is deprived of all foun- 
dation when applied to ordinary cases ; that the prolongation of the 
osseous fibres is only seen in callus in a very advanced stage, and 
never at the beginning ; that Bordenave, introducing the vesicular 
tissue after having admitted the effusion of lymph, has taken for a 
primary and constant phenomenon one which is consecutive and quite 
rare; that Duhainel, who so carefully observed the engorgement of 
the periosteum and medulla, did not see that this was due to liquid 
effusion, whether of blood, or of lymph; and apart from all these 
theories, we shall confine ourselves to the only two actual doctrines 
which dispute the precedence ; the old doctrine of the osseous juice, 
and the modern one of sanguineous effusion. 

As I cannot profess much respect for the priority of Antoine de 
Heide and his experiments on frogs, I shall credit properly the fol- 
lowing two principal theories : the first actually conceived by Galen, 
verified by Haller, Dethleef, Troja and others ; the other coming 
essentially from J. Hunter, and submitted to experimentation by 
Howship and M. Breschet. What is especially remarkable is that 
they were not deduced from particular observations or experiments, 
like most others ; but that they were proposed as it were a priori, or 
rather as consequences of more general ideas concerning the restora- 
tion of divided parts ; Galen teaching that every solution of con- 
tinuity was repaired by means of the nutritious juice proper to each 
part, and Hunter attributing the same function to effused blood. 
And if anything in this history would justly excite our wonder, it 
would be the sight of modern genius overcome by ancient, of John 
Hunter yielding to Galen. 

The first phenomenon revealed by the scalpel at the seat of a 
fracture, is an effusion, more or less abundant, of blood ; this is pro- 
bably never wanting. For my own part, I have never failed to find 
it, and the opinions of Antoine de Heide, Duhainel, Howship and 
M. Breschet are unanimous on this point ; we must doubtless ascribe to 
some singular preoccupation the entire omission of any mention of it 
by Dethleef, Haller, Fougeroux and Troja. We should, however, 
remember that when a fracture takes place with the least possible 
disturbance of the parts, the periosteum even remaining unbroken, 
the effusion is very slight ; increasing in proportion to the injury 
inflicted on the periosteum, medullary tissue and muscles, by the 

Duhamel. Mfrm de VAcad. Roy ale des Sciences; Fougeroux, M6m sur les Os, 
Paris, 1760, 8vo ; Haller, Dethleef, Bordenave, in the work of Fougeroux ; 
Troja, De nov. ossium regener. experimenta, LutetiaB, Paris, 1775, 12mo ; 
Camper, in Essays and Obs. of Society in Edinburgh, 1771, vol. iii ; J Hunter, 
On the Blood and Inflammation; Bichat, Anat. Gre'ntrale; Howship, Experi- 
ments, etc., in Medico-Ghirwrg. Transactions, 1817, vol. ix ; Breschet, TJitse 
de Concours, Paris, 1819. • 



104 A TREATISE ON FRACTURES. 

separation and overlapping of the fragments. In the former case 
the blood is poured out in the medullary tissue at the level of the 
fracture, a little of it also passing between the fragments and be- 
neath the periosteum ; in the other cases, the effusion occurs in all 
the torn tissues, and even traverses the cellular tissue for a consider- 
able distance. 

After a time, varying with the age and species of the animal, com- 
mences the effusion of coagulable lymph, which seems gradually to 
take the place of the blood, the latter being reabsorbed, Dethleef 
succeeded in detecting this lymph at the end of eight hours, in a frac- 
ture of the humerus in a young dog ; but at the end of twenty-four 
hours, it is unanimously testified to by Duhamel, Fougeroux, Troja 
and M. Breschet. It is singular that Howship alone did not perceive 
this, though very earnest in his examination of the clot ; a preoccu- 
pation fully equal to that of the partisans of the other theory. 
Troja has studied with the microscope the effusion of this lymph; he 
has seen it poured out in the form of small grains, first between the 
fractured surfaces, and then between the periosteum and the bone ; 
but other experimenters have been satisfied with the naked eye. It 
finally infiltrates the periosteum ; and this result once attained, Du- 
hamel fixes on it to the exclusion of everything else ; but Dethleef 
shows that it is actually the lymph which does this, and M. Breschet 
has since established the occurrence of the same infiltration in the 
surrounding cellular tissue, as far as the sheaths of the muscles, pro- 
vided there is a passage given it by a preceding rupture. 

The lymph, once thrown out, is soon coagulated, and the forma- 
tion of its vessels begins. At the fourth day, in a young dog, Deth- 
leef observed red points in the midst of the coagulable lymph, and 
considered them as so many centres of commencing ossification. 
Troja, from the fourth to the seventh day, found the fractured ends 
ioined by numerous fleshy fibres, which, if torn across, left only red 
points on the bony surfaces ; but examined with good microscopes, 
these points appeared concave, assuming the aspect of torn vessels. 
M. Breschet showed, on the second day, the presence of red points 
on the fractured surfaces ; he thought them formed of blood, and 
that from their development came the red, softish, filamentous sub- 
stance, observed both by him and Troja from the fourth to the sixth 
day. Thus we see three explanations of the phenomenon : points 
of ossification, newly formed vessels, or fibrinous tissue. Howship 
seems to have solved the enigma. At the fifth day, in a rabbit a 
year old, a very fine injection filled in a surprising manner the ves- 
sels of the cellular tissue, of the periosteum, and of the marrow; to 
explain the participation of the cellular tissue in this vascularity, 
it should be stated that the fragments were overlapping. At the 
point where the fragments overrode one another, there were found 
between the periosteum and the bone evidences of an osseous secre- 



A TREATISE OX FRACTURES. 105 

tion, in the form of a white, rugose deposit, visible with the micro- 
scope. Thus the commencement of ossification is here placed beyond 
doubt, and the white or red color of the bony points is of small im- 
portance ; but how are we to explain this ossification, seen by How- 
ship at a time when, as he says himself, no vessel yet penetrated the 
clot ? Evidently the callus had commenced outside of the clot ; its 
whiteness forms another argument against their being in any way 
connected. It was not till the ninth day that the clot lost its color- 
ing matter ; but Howship has omitted to state how he ascertained 
that this blanched clot was actually blood, and not lymph. His ob- 
servations, then, accord with those of all the other experimenters; 
but he was the first to follow the development of the vessels, finding 
them abundantly formed, first in the periosteum, passing obliquely 
from its inner surface to the bone, and afterwards in the medullary 
membrane. He adds that the innermost part of the clot, the portion 
lodged in the cells of the medullary membrane, is also filled with 
vessels ; and this is the last prop of his theory. But M. Breschet, 
following him, has ascertained that the red substance called clot by 
Howship was a new formation of fibrous tissue, found likewise be- 
tween the fragments themselves. 

What need is there of further combating a theory which has not 
yet been supported, either as regards the soft parts or the bones, by 
any well demonstrated facts ? English surgeons have vainly sought 
to find a single example of organisation of a blood-clot — that is, of 
its vascularisation ; and they themselves oppose the doctrine of their 
great master. 

To sum up, then, the callus is formed by an effusion of plastic 
lymph, probably secreted from the periosteum and medullary tissue, 
perhaps also by the surfaces of the fracture ; this lymph infiltrates 
the adjoining tissues, but especially the periosteum and medulla; 
afterwards it is organised, becoming penetrated by blood-vessels, and 
takes the place of the clot, which is absorbed. It is worthy of re- 
mark that a very considerable effusion of blood is an obstacle to 
consolidation. 

So much for simple fractures, or such as are not exposed to the 
air ; as to such as are so exposed, whether by the original injury 
wounding the soft parts, or by suppuration, I know of no one who 
mentioned them before John Hunter ; and this great observer, com- 
paring them with suppurating wounds of soft parts, thought that 
their consolidation was effected by granulations developed on the two 
fractured ends ; which granulations became subsequently ossified. 
Dupuytren embraced this theory, which seems by no means in ac- 
cordance with the facts. M. Breschet has made it certain that the 
obliteration of the medullary cavity follows the same course as in 
simple fractures, and that the ends of the external osseous ring do 
the same. Only he adds that granulations arise on the surfaces of 



106 A TREATISE ON FRACTURES. 

the fracture, on the uncovered parts of the ring, from the internal 
osseous pin, and lastly from the soft parts ; and that in the bone and 
the callus this formation of granulations goes on by means of an 
intermediate layer of substance resembling cartilaginous, fibrous, or 
fibro-cartilaginous tissue. 

I have fully recognised the justice of the first results obtained by 
M. Breschet, which of themselves suffice to shake the doctrine of 
Hunter and Dupuytren ; but I do not allow so much importance to 
the granulations as M. Breschet would. From what I have been 
enabled to observe in man, the effusion of coagulable lymph always 
occurs where the air does not penetrate, and fills even the interstices 
of the fragments when these are so retained in position as to prevent 
the access of air. Granulations only arise in suppurating parts ; so 
far from aiding consolidation, they are only produced at the expense 
of the bones, which are hollowed out or absorbed before them wherever 
they are developed. When, in the most complicated cases, suppura- 
tion has entirely laid bare the ends of the bones, and these are eroded 
and covered with granulations, it is necessary for reunion that a spe- 
cial effusion of lymph should occur between the opposing surfaces ; 
and it is in this lymph that ossification takes place, and by it that 
the loss of substance is made up. On the contrary, when an osseous 
surface remains isolated, out of relation and without any possibility 
of union to the other surface, no new ossification ensues, and the loss 
of substance, filled up merely by granulations, always remains 
perceptible. 

I shall cite as an example the compound fracture of the leg repre- 
sented in Fig. 7. A woman, aged 50, was overthrown by the fall of 
a cask, breaking her right leg ; the lower fragment of the tibia pro- 
jected more than an inch through a large rent in the integuments. 
It could be easily reduced, but not retained in position ; one portion 
became necrosed ; gradually the granulations reached the limits of 
the necrosis, and all was going on well, when symptoms of purulent 
absorption came on, and proved fatal on the eighteenth day. 

In the drawing is seen the lower fragment of the tibia, necrosed 
at its upper end. The edges of the necrosed portion are serrated, 
as if worm-eaten ; and it may be added that below they are hollowed 
out to the depth of one or two millimetres. Between the edge of 
the necrosis and the sound bone is an interval three or four millime- 
teres wide on the inner, and three or four times as much on the outer 
side ; in all this interval the bone is eaten away one or two millime- 
tres below its natural level. The bottom of this erosion, in the fresh 
specimen, was composed of bony tissue, hard, but reddish, present- 
ing longitudinal striae separated by ridges; these ridges were redder 
and less firmly resistant to the scalpel. 

The granulations are no longer seen ; they constituted, over the 
whole extent of the eroded portion, a reddish, soft, slightly adherent 



A TREATISE ON FRACTURES. 107 

membrane, sending out fungous prolongations under the edges of the 
necrosed portion ; on these latter doubtless devolved the function of 
detaching by absorption the whole of this large mortified part. 

But at any rate, here the granulations stopped. As the necrosis 
had not invaded the entire thickness of the fragment, between the 
living portion of the fractured surfaces was a soft, tomentose, reddish- 
brown substance, adhering to all the corresponding parts of those 
two surfaces ; if torn up, beneath it were reddish strige similar to 
those found beneath the true granulations. The splinter was like- 
wise united to the upper fragment, and this same red tissue had filled 
all the interspaces and angles between both fragments and the splin- 
ter ; it jutted out even to the periosteal face of the latter, and there 
began to become ossified, without any trace of the formation of car- 
tilage. This commencing ossification was entirely soft and spongy ; 
some portions of it remained on the dry specimen, and hence appear 
in the drawing. 

To any one who, not having seen the thing itself, can only judge 
from the description, a very natural objection will occur : was not 
this reddish tomentose tissue formed by the junction of granulations 
springing originally from each surface ? But this very instance fur- 
nishes the most decisive answer ; the two fractures of the fibula, one 
at least of which did not communicate with the external wound, were 
united by a similar reddish tissue, beginning to ossify in its most ex- 
ternal layers. I shall before long have occasion to recur to this 
tissue. 

There may also be remarked in the drawing the numerous porosi- 
ties, occupying mainly the tibial splinter (except at the inner angle, 
where the necrosis was) and the lower fragment. These porosities, 
which show here and there little ridges, denote a superficial inflam- 
mation of the bone almost constantly found where a fracture is fol- 
lowed by suppuration. The more active the inflammation at the 
seat of fracture, the more widely extended are its traces on the sur- 
face of the bone ; so that in gunshot-fractures the whole bone some- 
times appears thus marked by porosities and ridges. Of this there 
is a fine example in the museum at Val-de-Grace, in the femur of a 
Swiss wounded in 1830, who lived until the bone was completely 
consolidated. 

[An excellent account of the process of repair of fractures is 
given by Paget, in his "Lectures on Surgical Pathology."] 

§ III. — Of the Transformations of the Callus. 

We have traced the callus up to the time when it is abundantly 
traversed by blood-vessels, and therefore already endowed with a com- 
plete organisation ; but this organisation is merely temporary — a 
step toward ossification, the great end of the reparative process. 



108 A TREATISE ON FRACTURES. 

Surgeons have not studied this latter part of the history of the callus 
much better than the former. 

The oldest idea, dating as far back as the " Prsenotiones Coacse," 
is that bones when broken do not again unite. Perhaps obscure in 
the writings of Hippocrates, it becomes very clear and positive in 
those of Galen. The latter, having studied the callus in different 
animals, having scraped off the newly-formed osseous matter, and 
found below it the fragments not yet joined, concluded that in the 
bones there was not, as in the soft parts, direct union ; but only a 
sort of intermediate soldering of the parts, as when two bits of wood 
are held together by a ferrule. This comparison is in some degree 
just ; and Galen himself had noted as an exception that in young 
subjects direct union might occur. 

Modern authors have misconstrued Galen's comparison of the 
callus to a ferrule, understanding him to say that the former was not 
organised. But it might as well be inferred, because Galen compared 
the fragments to two pieces of wood, that he regarded the bones as 
destitute of life. 

In giving the old doctrine its true meaning, we are justly surprised 
at the long course taken to return to this point of departure, and we 
see that we have added to it but very little. Thus Duhamel con- 
cluded from all his experiments that the reunion of the bones was 
only direct in very young animals ; but attributing the main action 
to the thickened periosteum, he was the first to speak of the suc- 
cessive transformation of this into cartilage and into bone. The 
entire formation of the callus was thus comprised in three distinct 
periods. Haller went further, and making the callus originate in a 
gelatinous juice gradually thickened to a sort of jelly, ascribed to it 
three new transformations : (1) into cartilage ; (2) into spongy osse- 
ous tissue ; (3) into compact tissue. There was, then, a new period 
added to those of Duhamel ; nothing else was changed except, as 
we have seen, the explanation of the original period ; and Haller has 
even omitted in his theory the case of direct union. Dupuytren per- 
ceived this gap, and thought to fill it by instituting a fifth period, in 
which the fragments became united end to end, by a definitive callus ; 
the four preceding periods belonging to the provisional callus. But 
as the definitive callus formed, the provisional, becoming useless, 
gradually disappeared, the bone thus returning to an entirely normal 
state. This theory of Dupuytren's, which completed the others, and 
seemed to account for all the facts, gained great favor, especially in 
France ; to adapt it to practical wants, he has defined the duration 
of each period : 

First period, engorgement of soft parts, first to eighth or tenth day. 
Second period, formation of cartilage, tenth to twentieth or twenty- 
fifth day. 

Third period, formation of spongy bone, twentieth or twenty-fifth 



A TKEATISE ON FRACTURES. 109 

to thirtieth, fortieth, or sixtieth, according to the age, constitution 
and health of the patients. 

Fourth period, formation of compact bone, fiftieth or sixtieth day 
to five or six months. 

Fifth period, formation of definitive callus, completed by the 
eighth, tenth, or twelfth month. 

There is one objection which holds alike against all these theories. 
Andre Bonn, without denying the cartilaginous transformation in 
animals, affirms that it never has been seen in man ; in whom the 
callus, according to him, is first fleshy, becoming afterwards fibrous 
and like skin, and then passing at once into bone. Macdonalcl has 
observed that even in animals the callus may be reddened, while in 
the cartilaginous stage, by the use of madder, which is not the case 
with true cartilage ; whence he concludes that the plastic lymph is 
directly transformed into bone, at first soft and flexible, and after- 
wards solidified by the deposition of calcareous salts. This explana- 
tion allows to the experiments all their force, but changes their inter- 
pretation ; while Bonn's assertion would lead to their rejection as 
inapplicable in the case of man, and may hence be seriously disputed. 
Two questions arise : first, is it true that experiments on animals 
always show the cartilaginous transformation ? secondly, is it true 
that this transformation is never seen in man ? 

We have already said that Dethleef claimed to have seen osseous 
grains at the fourth day, in a tumor which had not yet passed into 
the cartilaginous condition; and that Troja and M. Breschet had 
pointed out the existence, between the fractured surfaces, of a fibrin- 
ous tissue ; the last-named observer has likewise seen it between 
displaced fragments, holding them together. Howship also declares 
that about the ninth day, while the osseous transformation is going 
on in the external tumor, which is entirely cartilaginous, it has com- 
menced in the red tissue filling up the medullary canal, which, ac- 
cording to him, is the remains of the clot. It is true that neither 
Duhainel nor Dethleef make any mention of this red tissue ; but 
they also pass over the effusion of blood, the reality of which is 
beyond doubt. Dupuytren says that the red tissue is sometimes 
wanting ; but we have no details of his experiments, and it may be 
that he drew this conclusion from those of Dethleef and Duhamel. 
However this may be, there is seen even in animals an ossification 
occurring in an apparently fibrous tissue, without any cartilaginous 
stage ; and this commencing ossification in the medullary canal is 
much more rapid than that of the external tumor. This latter, on 
the contrary, appears always to have a cartilaginous aspect, although 
wanting many of the characters of true cartilage, and essentially 
differing from it in having a tendency to ossify. 

There remains the second question : Is it true that in man the 
callus never goes through a cartilaginous stage? A. Bonn would 



110 A TREATISE ON FRACTURES. 

think so, from all the observations made by him ; and I should be 
of his opinion entirely, were I to speak here only from what I have 
myself seen. I have mentioned recently a case in which the callus, 
twenty days old, consisted of a reddish tomentose tissue, in which 
ossification had begun. I have elsewhere published an account of a 
double fracture of the femur, thirty-five days old, in a patient fifty- 
three years of age. There was as yet no attempt at union between 
the fragments, and, let this be noted, the delay seemed owing entirely 
to the too large quantity of blood effused ; but between a large splin- 
ter and the upper fragment appeared a broad reddish membrane, 
already interspersed with points of ossification. Likewise in a man, 
aged 45, affected with fracture of the os calcis, who died on the forty- 
ninth day, the numerous intervals separating the fragments were just 
filled by a bony tissue, redder, softer, and less dense than the rest 
of the bone ; and in several places the reunion was only accomplished 
by a soft, tomentose, and membraniform substance.* I cite only 
these three cases, adding, however, that in none of the autopsies in 
which I have been enabled to examine imperfect callus have I found 
any appearance of cartilage. 

But I do not feel authorised to draw a conclusion as absolute as 
that of Bonn ; and as my own experiments on animals have led me, 
like all other experimenters, to see the cartilaginous transformation, 
as also my autopsies have been only in adults or old persons, I ask 
myself if the animals we make use of do not represent the young 
human subject, and if in infancy there might not be found a cartila- 
ginous period of the callus. A. Bonn himself has unintentionally 
furnished a fact in support of this presumption. He had, in the 
Museum of Hovius, the clavicle of a little girl four months old, 
fractured, half consolidated, and preserved in alcohol, without the 
periosteum. " This imperfect callus," says he, "by its external 
aspect, its whitish color, its hardness and elastic flexibility, resembled 
cartilage ; but with a lens it was seen to have an outer layer of bone, 
fibrous, porous, grooved, entirely analogous to the osseous nuclei 
developed in the cartilaginous epiphyses of the long bones." This 
last argument of Bonn's loses all its force since we admit that even 
in animals there is only an apparent and not a true cartilage. In 
another child, three years old, rachitic, who died the seventieth day 
after a fracture of the femur, he found likewise the periosteum 
swollen, of a reddish-white color, and more, he says, like skin than 
like cartilage ; and yet a lamella of this new tissue showed a carti- 
laginous translucence.f Here, indeed, there was a specimen of what 
M. Breschet, for instance, has designated in his experiments as fibro- 
cartilaginous tissue ; and on the whole it appears that plastic lymph 

* See the Gazette Mtdicale, 1836, p. 170 ; and my Journal de Chirurgze, 
tome i, p. 9. 
t JDescr : TJiesauri Oss. Morbos. Hoviani, pp. 164= and 165. 



A TREATISE ON FRACTURES. Ill 

in children takes the form of cartilage before ossifying, while in adult 
age it is organised into a reddish fibroid membrane, and from that 
passes directly into bone. 

There is then, in this point of view, some objection to the majority 
of modern theories. Other no less serious difficulties exist as regards 
the fourth period of Duhainel and Dupuytren, viz., that of trans- 
formation of the spongy tissue of the callus into compact tissue, and 
the simultaneous formation of definitive callus. 

Inquiring of experimenters in regard to this, we are surprised at 
the small number and the almost insignificance of their observations. 
Dethleef examined a fracture of the leg in a dog at the fifty-fourth 
day. The exterior callus was still partly cartilaginous ; in the me- 
dullary cavity it was partly dense, partly osseous and cellular. An- 
other fracture, involving both bones of the forearm, was dissected 
on the ninetieth day. The callus of the radius was spongy, and the 
fragments still slightly movable ; the ulna, on the contrary, was so 
solidly joined, that on sawing it lengthwise the callus was only recog- 
nised from the red stain caused by the use of madder. Borclenave, at 
the forty-fourth day, found the callus externally redder than the rest 
of the bone ; but he did not saw it open. Duhamel broke the leg of a 
lamb a month or six weeks old ; at the end of two months he found 
it so well united that he could not distinguish the fragments. The 
same result was obtained in a lamb killed at the end of four months. 
All this by no means shows the transformation of spongy callus into 
compact tissue ; and I know of no experiments more conclusive than 
these. 

Now, do autopsies speak more plainly ? We meet with three in 
Dupuytren's Lecons Orales, of fractures of the tibia and of the 
femur, examined after fifty-eight, eighty, and ninety-four days re- 
spectively. In the first the callus was spongy ; but wait a little. 
In the second the callus is again spongy. Lastly, it is still altoge- 
ther spongy in the third case ; so that these three cases, belonging 
only to the third period, prove nothing as regards the fourth ; and 
moreover, they show this "third period to have been prolonged beyond 
the time assigned it by Dupuytren. 

I have, however, seen fractures united by an entirely compact cal- 
lus ; I possess a very fine specimen of this in a fracture of the tibia, 
with slight displacement transversely, and have seen others in which 
the callus was compact at the exterior, forming a shell of greater or 
less thickness around the still spongy central portion. Doubtless it 
was a combination of cases analogous to these by which Dupuytren 
was misled ; but scientific exactness cannot accept as complete and 
general a theory based on so small a number of facts. Here, then, 
is the real state of our knowledge in this respect : 

In the great majority of fractures preserved in our museums, the 
callus is spongy ; very rarely it is changed into compact tissue. 



112 A TREATISE ON FRACTURES. 

We do not know at all whether or not this transformation is con- 
stant, and much more probably it occurs only exceptionally. 

We do not know at all the circumstances under which it occurs, or 
the time requisite to accomplish it ; and the assertion of Dupuytren, 
fixing this as from the second to the sixth month, is entirely 
chimerical. 

But at any rate, whatever may be the state of the provisional cal- 
lus, is there always a definitive callus, or complete union of the frag- 
ments ? Galen admitted its occurrence, but only in young subjects ; it 
has been obtained in animals, where there had been no displacement. 
I would willingly believe that such is sometimes the case in human 
adults ; but I must confess I have seen only the instance cited above, 
which might just as well be used to prove the compact ossification of 
the provisional callus. Sometimes I have seen the fragments, even 
in contact, retain a linear trace of separation without any kind of 
alteration (see Fig. 37 ;) sometimes I have seen the broken ends not 
only remaining ununited, but themselves presenting a spongy texture, 
doubtless from the effect of inflammation of their former tissue (see 
Figs. 36, 68, and 70.) I make no allusion here to fractures through 
the spongy portions of bones, where the callus is from the beginning 
assimilated to the continuity of the bone. 

There remains, lastly, the fifth period, in which the provisional 
callus is superseded by the definitive or permanent. We see at once 
that in all cases where the fragments are too much separated to re- 
unite end to end, definitive callus, as understood by Dupuytren, cannot 
be formed, and the provisional callus must become permanent. We 
see also that when the fragments, placed end to end, do not directly 
unite, the disappearance of the provisional callus can hardly occur, 
since it would reproduce the fracture. We see, therefore, that this 
fifth period is reserved for those rare cases in which there is no dis- 
placement, and a definitive callus forms ; even then I should say that 
I know of not a single fact which could be adduced to prove the re- 
sorption of the provisional callus. Dupuytren himself has cited 
none ; and so the theory is once more reduced to a pure hypothesis. 

As regards the interior callus, M. Lambron has carefully ex- 
amined all the fractures in the Musee Dupuytren, and those in 
M. Gerdy's collection; he has even had sawed open bones fractured 
years before, the external surfaces of which were perfectly regular, 
and has always found the canal interrupted at the seat of fracture, 
either by layers of compact tissue, or by a spongy network. Cam- 
per has always met with a septum of compact tissue; from this, in- 
deed, he was led to state that the interior callus was formed by pro- 
longations of the fibres of the diaphysis, meeting one another across 
the canal. I cannot for my own part be as positive as Camper, or 
even as M. Lambron. Most commonly, it is true, I have found the 
interior callus compact; sometimes spongy, as is beautifully shown 



A TREATISE OX FRACTURES. 113 

in Fig. 37 ; but I have had represented {Fig. 36) the callus, other- 
wise very irregular, of a humerus, in which the spongy tissue only 
very imperfectly fills the medullary canal, leaving a communication 
between the fragments. I would not hence conclude that here an in- 
terior callus had been absorbed, for there are fractures in which the 
interior callus is from the beginning very incomplete; and in Figs. 
76 and 77 may be seen an exterior callus already partly ossified, 
but hardly any traces of an interior callus. 

The same may be said of the external callus ; M. Lambron asserts 
that it may disappear entirely, which is rare, or only in part, which 
is more common; but he himself admits that some fractures unite 
without any exterior callus; and Duhamel and Troja have found by 
experiment that in animals a compressing apparatus hinders the 
formation of the ring. When, therefore, we meet with a fracture 
consolidated without any such ring, we have no right to say that this 
latter has been absorbed, without first proving that it was really 
formed. 

But in place of this hypothetical resorption, M. Lambron has 
studied another form differing from it both in cause and in results. 
The cause here is the compression or the motion of the muscles upon 
a superabundant callus; or rather upon the projection of the frag- 
ments themselves. "Thus," says this author, "one may see in the 
Musee Dupuytren several fractured femurs in which the superior 
fragment, overlapping the inferior, is transformed into a sort of 
spike, from being worn by the to-and-fro motion of the rectus femoris 
(in the flexion and extension of the leg) and laterally by that of the 
vasti."* These observations are very just. I have had represented 
[Fig. 73) a femur in my collection, in which can be plainly seen the 
wasting and thinning of the external wall of the shaft where the 
upper fragment was compressed by the vastus externus. Fig. 85 
shows another femur in which the upper fragment, projecting for- 
ward, has been wasted by the pressure of the quadriceps. All sharp 
points are thus blunted or finally removed, according to the greater 
or less amount of pressure exerted upon them. 

The doctrine of the formation of the callus may therefore be 
summed up in the following propositions. 

(1.) The callus, taking its origin from an effusion of lymph, as- 
sumes at first the form of a reddish tissue, which passes afterwards 
into spongy bone. These are the three principal phases of the re- 
union of bones, and for this reason I admit in the living subject but 
three periods, corresponding to them as nearly as may be. 

(2.) In young subjects the reddish tissue is in great measure re- 
placed by a tissue of a fibro-cartilaginous aspect, which would per- 
haps be more properly called fibro-gelatinous. 

* E. Lambron, Thtse Inaug., Paris, 1842, No. 203. 



114 A TREATISE ON FRACTURES. 

(3.) The formation of spongy bone is the last phase of the callus 
in fractures of the spongy bones, and in the majority of other frac- 
tures. Sometimes, however, there is a transformation into compact 
tissue. 

(4.) Immediate union, the rule in fractures of the spongy bones, is 
very rare in those of the diaphyses. The fragments in these latter 
appear under three different forms ; sometimes enveloped in spongy 
callus, but without having themselves undergone any alteration ; 
sometimes thinned out and pierced into cells connecting closely with 
those of the callus, or lastly sometimes joined end to end without 
any trace of the previous division. 

(5.) In general the medullary canal is obliterated by a septum of 
compact tissue, or by a plug of spongy tissue. This obliteration 
occurs even when the fragments are entirely separated; it is seldom 
wholly wanting. 

(6.) In general also the callus forms a ferrule more or less solid 
around the ends of the bone. Sometimes this is naturally wanting, 
especially in simple fissures ; or its development may be hindered by 
means of pressure. But when once ossified, it is not reabsorbed; 
and all resorption of projections about a fracture is due to pressure 
by muscles or other surrounding tissues. 

All this, however, applies only to bony fragments endowed with a 
certain degree of vitality; it gives us no information concerning 
either splinters, or fractures involving articular cartilages. 

John Hunter was the first to study the subject of splinters. In 
simple fractures (without any external communication) he had seen 
that they contracted adhesions, and lost by absorption their asperi- 
ties. MM. Breschet and Villerme have made some very curious ex- 
periments on this subject, with the following results.* 

Splinters having no vital connections, if of a certain size, always 
determine inflammatory symptoms, in consequence of which they are 
expelled, unless life should be destroyed; when very small, they 
often remain in the part without serious inconvenience. 

After a month, in the case of dogs, these little splinters, ordinarily 
imbedded in the substance of the forming callus, had undergone no 
sensible change, but presented the same aspect as on the first day. 
At the end of two months one could still recognise the outer and 
inner surfaces of the cylinder of which they had formed part; but 
these surfaces were roughened, and the fractured edges were thinned, 
showing here and there little points not seen in the recent state. 

At four months, the thickness was everywhere diminished; the 
edges sharp, undulating, with points of greater or less length and 

* Des Esquilles qui Compliquent les Fractures; Journal de Physiologie 
Experim., tome i, p. 116. This memoir alone bears the name of both authors ; 
but M. Breschet has in several passages said that the experiments for his These 
de Concours were likewise made in common with M. Villerme. 



A TREATISE ON FRACTURES. 115 

sharpness; opposite a very long point there was generally on the 
other edge likewise one longer and larger than its neighbors. The 
inner and outer faces could no longer be made out except by the 
general curvature of the fragment. Sometimes at this period there 
were seen very small, elongated, thread-like splinters, which certainly 
had not been detached in this form. 

Moreover, some time after the fracture, the splinters were always 
found imbedded in a red, softish tissue, essentially vascular, and 
very easily injected. 

Hitherto we have no evidence that the course of things is other- 
wise in man, except perhaps that in adults the splinters resist ab- 
sorption for a longer time. I have had drawn (Fig. 8) the splinters 
from a gunshot fracture of the tibia, received in 1815, which were 
extracted in 1823, eight years afterwards; all these splinters are 
white, compact, and appear irregularly hollowed out in the thickness 
of the wall of the shaft. In the two larger ones, the inner and outer 
surfaces can be easily distinguished ; the latter has been hardly at all 
affected by absorption. The largest of all is traversed on its outer 
face by a spiral fissure, involving only a portion of its thickness. 

Gunshot fractures, which usually give rise to a good many splin- 
ters, are frequently consolidated without the expulsion of these ; but 
the patients are apt to have pains, inflammation, and small abscesses 
about the seat of fracture; and every occurrence of this kind is 
ordinarily terminated by the discharge of a few splinters. I have 
seen several soldiers who carefully preserved scores of bits of bone, 
thus expelled from time to time even after fifteen or twenty years. 

There is, however, a distinction to be made among these splinters, 
which is clearly defined by Dupuytren. Some, dating from the mo- 
ment of fracture, are detached by the original violence; these are 
primary ; others, called secondary by Dupuytren, are the result of 
necrosis of the broken ends, and are separated from the bone by an 
eliminative inflammation. But this distinction, although theoreti- 
cally correct, is hard to make in practice when a certain time has 
elapsed since the occurrence of the injury; for instance, I would not 
venture to say whether the splinters in Fig. 8 were primary or 
secondary. 

As to fractures of the articular cartilages, there has never been 
seen in them even an attempt at reunion. Fig. 79 shows a division 
of this kind, in the cartilage of a patella which is itself well con- 
solidated. The drawing was made from the specimen after its ma- 
ceration in water for the purpose of softening the cartilage, the 
separation of the borders of which, in the dry state, was much more 
marked; giving the idea of a much greater loss of substance than 
had really occurred. 

The mode of union of the costal cartilages will be discussed in 
another chapter. 



116 A TREATISE ON FRACTURES. 

[In the chapter on " The Repair of Fractures," in Paget's "Lec- 
tures on Surgical Pathology," will be found an admirable discussion 
of the subject of this section.] 

§ IV. — Theory of Anchylosis following Fracture. 

This question, upon which the authors of the last century hardly 
touched, is perhaps still somewhat undecided. J. L. Petit alleged 
that in fractures bordering upon or involving articulations anchylosis 
ensued from the deposition of callus either within or about the joints; 
in others he attributed it to thickening of the synovia, from want of 
motion. To this thickening was added by Duverney the stiffness or 
contraction of ligaments and muscles. Boyer drew a distinction be- 
tween the anchylosis produced by immobility, and due at the same 
time to a lessened synovial secretion, that due to stiffening of the 
ligaments and muscles, and that due to engorgement of the sur- 
rounding soft parts; according to this author, a slight amount of 
inflammation, added to want of motion, led to adhesions like those of 
serous membranes ; and he proved by dissection that the inspissation 
of the synovia and the intra-articular formation of callus were mat- 
ters of pure hypothesis. These ideas, going back as far as J. Hun- 
ter, were quite generally admitted until a pupil of the Lyons school, 
M. Teissier, endeavored to rectify them, and to show that want of 
motion alone, unconnected with inflammation, could induce : 

(1.) Simple and purely muscular stiffening of joints. 

(2.) Effusion of blood or of serum in the articular cavities. 

(3.) Injection of the synovial membranes, and the formation upon 
them of layers of lymph. 

(4.) Alteration of the cartilages without adhesion of the articular 
surfaces. 

(5.) Fibro-cellular anchylosis. 

This doctrine is based on five observations, which deserve ex- 
amination.* 

The first was in a man aged 60, with an oblique fracture at about 
the middle of the femur; he died at the end of three months, exten- 
sion by means of Boyer's apparatus having been constantly kept up 
throughout this time. He had had no pain in the articulations. 
Nevertheless it was found at the autopsy, that the knee-joint of the 
affected side contained a large quantity of effused blood; the carti- 
lages were here and there destroyed to one-half or the whole of their 
thickness, by ulceration, around which there was some injection; 
they were easily detached from the bones, which were unaltered. 
The tibio-tarsal articulation displayed also an effusion of blood, its 

* Gazette Mtdicale, 1841, pp. 609 and 625. 



A TREATISE ON FRACTURES. 117 

cartilages were yellowish and had lost their polish, and the synovial 
membrane was thickened and injected. 

In a woman aged 70 years, who died at the sixty-eighth day after 
a fracture of the cervix femoris, treated with Desault's splint, there 
was likewise found an effusion of blood in the knee-joint ; the carti- 
lages were roughened, yellowish, injected, eroded at various points ; the 
synovial membrane seemed infiltrated with blood; the lateral liga- 
ments engorged, and imbedded in condensed cellular tissue. The 
third case, analogous to these two, was one of fracture of the cervix 
femoris treated by extension, and examined five months after the 
accident. 

Such then are the marked alterations found from the second to 
the fifth month after the fracture. The other two cases go to show 
the effects of loss of motion prolonged from fifteen to twenty-two 
months. 

A man of thirty-six sustained, at about the lower third of the left 
leg, a comminuted fracture, which was complicated by suppuration, 
necrosis, and the formation of fistulae ; at the end of five months he 
was made to try to walk, but the leg swelled, the fistulse reopened, 
and at last amputation became necessary, fifteen months after the 
fracture. Dissection showed the astragalus and tibia soldered to- 
gether by their articular surfaces, by a white and fibrous tissue, 
allowing, however, of a very slight motion ; so also were the astragalus 
and os calcis ; in both joints the cartilages were thinned in some 
places, and in some places entirely gone. 

The fifth and last case is much more remarkable. A young man 
of twenty-seven, affected with oblique fracture at about the middle of 
the femur, was treated by permanent extension for the space of 
twenty-two months ; no callus was formed, and he therefore sub- 
mitted to amputation. The knee was swollen and stiff, and entirely 
incapable of flexion. The cartilage of the inner condyle of the 
femur and that of the corresponding surface of the tibia were found 
eroded to the extent of a franc-piece, a thin false membrane being 
interposed between them and extending to some distance over the 
rest of the cartilage. The external surfaces were joined by a strongly 
adherent false membrane ; moreover, at the point of greatest con- 
vexity of the femoral condyle, the cartilages of the two bones were 
entirely blended for a space of eight or ten millimetres, so that no 
trace of demarcation could be found between them ; they were not 
worn away at all, the single resulting cartilage having just the thick- 
ness of the two when isolated. A similar fusion had taken place 
between the patella and femur. In the tibio-tarsal articulation, 
there were found effusion of blood, very thick and adherent false 
membranes, and thinning and erosion of the cartilages. So also in 
the metatarso-cuboid, and in the phalangeal articulations. The 
bones, though softened and infiltrated with blood in their spongy 



118 A TREATISE ON FRACTURES. 

portions, did not present, says the author, the appearance of inflam- 
mation. 

These facts are certainly very remarkable, and however they may 
be interpreted, they warrant important practical inferences ; but since 
we are now concerned only in discussing tjie theory, do they entirely 
prove that mere want of motion can suffice to induce such unpleasant 
results? I answer without hesitation, no. I have given in my 
Anatomie Cliirurgicale, the observations of MM. Cruveilhier and 
Kuhnholtz, according to which entire immobility of the lower jaw 
for periods of sixty to eighty-three years had not led to fusion of 
the temporo- maxillary articulation. M. Teissier mentions these two 
cases, and justly adds, that fibrous anchylosis is much more rare 
after fracture of the upper than of the lower extremity. But he 
does not give the true explanation of this ; he looks for it in age, con- 
stitution, confinement to bed, etc., forgetting that in his own patients 
the hip-joint was exempt from the affections which involved the rest. 
Elsewhere, however, he is struck with this circumstance, and explains 
it by the difficulty of keeping this joint at rest. But I have recently 
examined a person who died more than ten months after the com- 
mencement of a psoas abscess which had kept the thigh immovably 
flexed, and found not the least trace of alteration in the joint. 

This one word, flexion, seems to me to give the key to the problem. 
The joints of the upper extremity are less liable to anchylosis, be- 
cause they are more readily kept flexed. Extend the carpal or the 
phalangeal articulations, and you cause formidable stiffening. All 
the patients mentioned by M. Teissier had the knee forcibly extended ; 
and we know well that complete and prolonged extension stretches 
and fatigues the muscles and ligaments, besides subjecting the arti- 
cular cartilages to severer pressure than any other position. Shall 
we blame only this continued pressure ? It suffices to explain the 
erosion, but for the formation of false membranes I consider adhesive 
inflammation as requisite. But, says M. Teissier, the patients never 
complained of pain in the joints ! Pain certainly is not an inevitable 
accompaniment of inflammation of this kind; and even outside of 
the joint, is there not evidence enough in the hard and compact 
engorgement of the cellular tissue, of the synovial sheaths, etc.? 
Has not M. Teissier twice seen hydarthrosis of the knee, without 
pain, ensue upon simple fractures of the thigh and leg, treated by 
extension ? Here certainly was inflammation. 

Moreover, there are some cases in which the inflammation is un- 
doubted, and manifest to any one. Now has it any other effect than 
that of causing effusions of serum, sometimes bloody, injection and 
destruction of cartilages, formations of false membrane, and en- 
gorgements of the surrounding tissues? Pain would then be the 
sole symptom distinguishing the one condition from the other ; but I 
have twice found thick and red false membranes in the hip-joint, 



A TREATISE ON" FRACTURES. 119 

after intra-capsular fractures of the cervix femoris; and as these 
formations could not be ascribed to want of motion, inflammation is 
the only available theory of their production ; yet in these two cases 
the patients had complained of no more pain than had others whose 
joints I found perfectly healthy. 

I think then that the adhesive inflammation plays a much greater 
part in the production of fibrous anchylosis than was supposed by 
M. Teissier; but this question is practically of only secondary 
moment. The really important conclusion to which this inquiry 
leads is that want of motion does not induce anchylosis, unless 
conjoined with extension of the limb. 

But aside from this disastrous termination, there very often re- 
mains, as has been said, a stiffening of the neighboring joints, the 
cause of which should be sought out. M. Teissier regards it as 
purely muscular; but this cannot be admitted. When we endeavor 
to give motion to these joints, it is not the muscles, but the ligaments 
which offer the principal resistance ; if a slight movement is forcibly 
made, pain is induced in the ligaments themselves, and swelling 
occurs around the joints; the symptoms brought on are exactly 
similar to those of a sprain, and have a like origin, — the stretching of 
the ligaments. How is it now that the ligaments should be stretched 
by movements not exceeding or even equalling their natural extent ? 
What meaning is to be attached to the words stiffening and contrac- 
tion, as employed by surgeons? 

It is very true that the ligaments, merely from being long kept at 
rest, tend to shorten, and that to a very notable degree. I have 
dissected fingers, long stiffened in a flexed position, and have more 
than once found the cartilages and synovial membrane sound, and 
the muscles free ; the ligaments alone prevented extension ; and if a 
sufficient force were exerted to obtain this, those fibres of the lateral 
ligaments closest to the surface of flexure were seen to stretch even 
to breaking. The tendons themselves become shortened; thus for 
instance the ligamentum patellae, which is really but the continua- 
tion of the tendon of the quadriceps, sometimes loses half its original 
length, drawing down the lower fragment and twisting it in the most 
singular manner. (See Fig. 81.) 

All positions of the limb are more or less conducive to contraction 
of the ligaments. In forced extension, it is those of the surface of 
extension which are relaxed, and hence which shorten most ; thus 
the knee, long kept straight, hardly ever recovers to the full its 
power of flexion. Forced flexion acts on the opposite ligaments; 
for instance the arm, long confined to the trunk, loses something of 
the motion of elevation toward the head. Semi-flexion shortens 
especially the lateral ligaments, hindering at the same time the ex- 
tremes both of stretching and of bending, as is particularly observa- 
ble in the elbow; so that the surgeon, surrounded by shoals, seems 



120 A TREATISE ON FRACTURES. 

r clear of one only to strike upon another. Let this idea then 
be borne in mind, as important to the successful treatment of frac- 
tures; that position, whatever it be, is injurious only when combined 
with a too prolonged want of motion; and that the limb should not 
be retained in this dangerous immobility for a longer time than is 
absolutely necessary. 

I shall not dwell upon retractions of the muscles themselves; 
these belong as much to the history of organic affections of the joints 
as to the subject of fractures. I shall only add that they are nearly 
always associated with some degree of paralysis of the affected 
muscles and of their antagonists, and thus is explained in great 
measure the weakness of limbs in which the work of consolidation 
has been slow. 

§ V. — Of Non-union, or False Joint after Fracture. 

Want of bony union, one of the most troublesome terminations of 
fractures, is happily also one of the rarest. It need hardly be said 
that reference is had here not to intra-articular fractures, in which 
union by fibrous tissue is almost the rule, but merely to fractures in 
the continuity of the bones, and chiefly in the long bones of the ex- 
tremities. No reliable statistics have as yet shown us the degree of 
frequency of this annoying termination. Walker, of Oxford, affirms 
that it occurred in only six or eight out of a thousand cases treated 
by him. Sir Stephen L. Hammick, of the Hospital at Plymouth, 
counted only three cases of this kind ; Liston says he had but one ; 
Pierson likewise mentions but one in a total of 367. At the Penn- , 
sylvania Hospital, among 946 fractures admitted from 1830 to 1840, 
union failed to take place in but one ; while thirteen cases of false 
joint presented themselves there from without, in the same space of 
time.* Lastly, according to Lonsdale, of nearly 4000 fractures ob- 
served during ten years at the Middlesex Hospital, there were 
scarcely five or six cases of non-union. 

As for myself, I have not as yet seen union fail in any case of 
fracture treated under my direction, and have had occasion else- 
where to observe only eleven instances. This cannot be compared 
with the experience of Amesbury, in London, who stated, in 1829, 
that he had seen already fifty-six cases, and two years afterwards 
that the number had increased to ninety. 

We know somewhat more nearly in what proportion false joint 
occurs in the different bones of the skeleton. Norris has drawn up 
a table comprising 150 cases, among which may be counted: 

* Norris, On the Occurrence of Non-union after Fractures ; American Jour- 
nal of the Medical Sciences, Jan., 1842. 



A TREATISE ON FRACTURES. 121 

In the humerus 48 

" femur -------48 

" leg 33 

" forearm -------19 

"jaw 2 

My eleven cases offer rather more variety. Four were in the 
humerus, two in the forearm, one in the femur, one in the leg, two 
in the clavicle; lastly, one was in a rib. 

M. Gueretin is preoccupied with another idea; and starting from 
this physiological law established by M. A. Berard, " Of the tivo ex- 
tremities of a long bone, it is always the one toward which the nu- 
tritious foramen is directed which earliest unites with the shaft of 
the bone," he inquires if this greater rapidity of the physiological 
process affects also the reunion of separated epiphyses, or that of 
fractures; and if consequently bony union is not oftener wanting 
in fractures situated toward the end away from which the nutritious 
vessel is directed. The facts collected by him would seem actually 
to solve the question in the way presupposed from the theory; to 
speak only of false joints, 

Of nine cases involving the humerus, five were in the upper half, 
and only four in the lower, toward which the nutritious foramen is 
directed. 

Of eight cases in the forearm, one alone was at the upper part, in 
the course of the artery ; seven in the lower. 

So also for the thigh and leg, making in a total of thirty-five only 
ten, or less than a third, occurring in the part of the bone traversed 
by the artery, and twenty-five in the other portion.* Other re- 
searches, made in England, give no slight support to this doctrine; 
Curling has announced that those fragments of long bones, from 
which the artery is cut off by reason of a fracture, undergo a sort of 
atrophy, presenting a larger medullary canal, with thinner walls, 
and a spongy tissue less dense But on the one hand, the facts 
given by Curling are very rare exceptions ; I have not seen one such 
instance in the public museums of Paris; and on the other hand, 
Norris has arrived at conclusions so different from those of M. 
Gueretin, that in a total of forty-one pseudarthroses, whose seats 
were clearly made out, twenty-seven were in the direction of the 
nutritious arteries, and only fourteen in the other portion of the 
bones. Adding together the two tables, we have seventy-six cases 
in all, of which thirty-seven occupied one part, and thirty-nine the 
other part, of the bones; the division could hardly be more equal. 

The male sex would seem singularly predisposed to pseudarthrosis, 
compared with the other. In Norris's table, the sex is indicated in 
147 cases, among which we find but eighteen women. My own ob- 

* See M. Gueretin's Memoir in La Presse Mtdicale, p. 45. 



122 A TREATISE ON FRACTURES. 

solvations have all concerned men, except a false joint in the humerus 
of a little girl of throe years. 

The question of age has here some interest, since on theoretical 
grounds it has l)oon stated that consolidation is more difficult in old 
people. I have therefore made a careful abstract of 104 cases, 
knowing the precise date of each fracture; and I have found the 
proportion to be as follows: 

Below 5 years 1 

From 5 to 10 years 2 

" 10 to 15 " 3 

" 15 to 20 " 4 

" 20 to 30 " 50 

" 30 to 40 " 19 

" 40 to 50 " 14 

" 50 to 60 " 6 

" 60 to 70 " 3 

Over 70 years _._.-. 2 

Whence it follows, in spite of common opinion, that old age pre- 
sents the fewest instances of non-union, and the period from twenty 
to thirty years the greatest number. 

It has been questioned whether or not different seasons and tem- 
peratures could have any influence in this respect; but hitherto the 
point has not been cleared up by observation. 

The effect of diet is less doubtful; Hewson has related the case of 
a man aged 35, affected with simple fracture of the tibia, who had 
been from the first subjected to copious bleedings, and deprived for 
six weeks of animal food, and who at the end of nine years still had 
a false joint. Noel has seen consolidation retarded for eight months 
in a girl of eighteen, of good constitution, whose relations had al- 
lowed her but six ounces of bread per diem ; six weeks of good nour- 
ishment sufficed for the formation of a solid callus. Other examples 
could be cited, but few of them are so remarkable as the two cases 
of fracture of the humerus, observed by Brodie in a man and woman 
confined for several months to one sort of diet, in order to lessen 
their embonpoint; in both, consolidation was wanting. These facts 
have their value, as showing that we must give nature, in the form 
of ample nourishment, the power necessary for the restoration of 
broken bones ; still, the danger of the attenuant treatment should 
not be overrated, when circumstances call for it. Norris reports the 
case of a young man of nineteen, with fracture of the thigh com- 
plicated with delirium, from whom 192 ounces of blood were drawn 
during the first fifteen days ; consolidation was completed in three 
months.* 

* Hewson, Mtmoire sur le Mdcanisme des Articulations Artificielles, etc. ; 
Journal du Progrls, tome ix, p. 161 ; Noel, Prix de VAcadimie de Chirurgie, 
tome v, p. 38 ; Norris, loc. cit. 



A TREATISE ON FRACTURES. 123 

Pregnancy has sometimes seemed to hinder consolidation. Fa- 
bricius Hildanus first noticed this; in a woman of thirty, seven 
months gone, whose leg had been broken by the kick of a horse, the 
fragments remained movable until the twenty-third week, and the 
callus was not completed until the thirtieth. Another woman, aged 
40, was suckling one child and two months gone with another, when 
she broke her leg. At the fortieth day, no callus forming, Fabricius 
made her wean the child ; but the fracture was unaffected until her 
delivery, after which it was consolidated in forty days. Hertodius, 
Alanson, Bard of New York, Condie of Philadelphia, and others, 
have reported analogous cases ; but instances of union during preg- 
nancy are far more numerous ; Hertodius has given one, Latta has 
himself seen four, Leveille and S. Cooper each one; Liston says he 
has seen several; and Amesbury, who among ninety cases of false 
joint saw but two in pregnant women, goes so far as to say that this 
peculiar condition was in them less accountable for the result than the 
insufficiency of the apparatus used. 

This assertion of Amesbury is too little in accordance with ob- 
served facts to merit any belief; but it remains to be explained why, 
in some cases, pregnancy hinders or retards union. Norris inclines 
to the idea that it has of itself no direct influence, but that it acts 
only according to the degree of debility induced by it ; in support of 
which he adduces three cases observed by Sir Stephen L. Hammick.* 
In the first, a fracture of the leg, occurring in the early months of 
pregnancy, remained for some time stationary; but the woman was 
extremely reduced by obstinate irritability of stomach preventing 
her retaining any aliment ; as her condition advanced, the stomach 
resumed its functions, the patient recovered her strength, and the 
fracture became united. Another woman, toward the close of her 
term, had the humerus broken; she was much exhausted; being de- 
livered, she endeavored to suckle the child; the fracture made no 
progress toward healing ; but the child being weaned, her strength 
returned, and consolidation ensued two months afterwards. Lastly, a 
third woman, likewise affected with fracture when near her accouche- 
ment, had no union ; she gave birth to the child, but did not suckle 
it, and her fracture was soon cured. 

These observations have their value ; Fabricius noticed that his 
first patient was small, weak and emaciated; but the second was fat 
and plethoric. Does obesity exert the same influence as leanness? 
Apart from pregnancy, we see persons both very fat and very thin, 
in whom fractures are united without difficulty. 

In some of the above-mentioned cases, it seems that lactation also 

* [Practical Remarks on Fractures, etc., by Stephen L. Hammick, London, 



124 A TREATISE ON FRACTURES. 

acted unfavorably upon the healing of fractures ; and several authors 
have not hesitated to count this among the causes of non-union. 

We must, however, correct here an error in words; the different 
physiological conditions enumerated too often fail in the effect at- 
tributed to them to merit the name of causes, and can at most rank 
merely as predispositions. - 

Among the general causes of non-union are likewise placed the 
diatheses or cachexies which we have already noticed in treating of 
the etiology of fractures, — scurvy, gout, cancer, syphilis, scrofula and 
rachitis. We exclude at once gout and scrofula, the influence of 
which is as little proved in one case as in the other. We have else- 
where sufficiently shown under what circumstances cancer hinders 
consolidation. Rachitis, except perhaps in cases of extreme wast- 
ing, seems rather to hasten union than to interfere with it. It re- 
mains for us to say a few words concerning the influence, in this 
respect, of scurvy and of syphilis. 

Scurvy appears incontestably to affect the formation of callus. 
Thus the Journal of Desault gives the history of an oblique fracture 
of the femur, complicated with a scorbutic tendency, in which the 
callus was not thrown out till the seventy-seventh day. In another 
subject, a like disposition retarded the union till the one hundred and 
fourth day. I have myself seen, at Bicetre, an extra-capsular frac- 
ture of the cervix femoris in a scorbutic old man, which at the ninety- 
fifth day showed no sign of reunion; he died, and I ascertained at 
the autopsy that there was not even a fibrous callus ; the fracture, 
but for some wearing away of the fragments, resembled a quite recent 
one. (See Fig. 6S.) 

The action of syphilis is more obscure. Sanson has seen two 
fractures refuse to unite, one for eight and the other for eighteen 
months, from its influence ; under anti-syphilitic treatment they were 
cured. Nicod, Beulac, and Condie, have seen like cases. But these 
are very rare exceptions ; we have already quoted from Marcus Donatus 
the case of a Portuguese in whom two successive fractures, attributed 
to constitutional syphilis, were readily healed. M. Lagneau has seen 
numerous instances of consolidation in analogous cases; Oppenheim 
also has observed such.* 

Lastly, violent fevers, smallpox, typhus, visceral inflammations, 
generally retard the process of healing; I have dissected a fracture 
of the thigh at the thirty-fourth day, in a man who had been in a 
persistent febrile state from the time of injury, dying at last from 
metastatic abscesses; the broken ends were surrounded by clots of 
blood, and union was hardly begun. 

The local causes of non-union are much more numerous ; they may 

* See A. Berard, Dcs Causes qui Empdcheni ou Retardent la Consolidation, 
Tkbse de Concours, 1833 ; Morris, loc. cit. 



A TREATISE ON FRACTURES. 125 

be classed under three heads, according as they affect the limb apart 
from the fracture, of which they are complications more or less 
direct ; or concern the fracture itself and the state of the fragments ; 
or lastly, are due to negligence or to some fault in the treatment. 

To the first class belong (1) paralysis; (2) obstacles to the circula- 
tion; (3) acute inflammations, such as erysipelas and phlegmonous 
abscess. 

(1.) Paralysis certainly has an influence which should be taken 
into account. In a case reported by Travers, there was at once 
fracture of the humerus, of the lumbar vertebrae, with paraplegia, 
and of the leg; the first was united in the usual time, the last not at 
all. Tuson has seen non-union in the fibula from a similar paralysis ; 
and B. Phillips ascertained at the end of five weeks, in an analogous 
case which terminated fatally, that the work of reparation had not 
even been begun. It must not however be supposed that there are 
no exceptions to this rule; Busk published in the London Medical 
Gazette, in 1840, the history of a man sixty-five years old, paraplegic 
for twenty years, entirely deprived of both motion and sensibility in 
his lower extremities, who nevertheless, having broken his left leg, 
had it entirely united at the end of five weeks. 

(2.) Ligature of arteries, above the fracture; has this really the 
effect of hindering the formation of callus? Dupuytren thought it 
had. In a woman aged 62, whose femoral artery he had tied for 
traumatic aneurism complicated with fracture of the leg, the callus 
was hardly begun at the close of a month; it had but little firmness 
at the end of the second month, and did not seem quite solid till 
after the fourth. But on the other hand, Delpech, having had a 
similar case in a man of thirty years, saw the callus completed much 
sooner; the patient walked without crutches at the ninety-second 
day. And lastly B. Cooper, having tied the crural artery in a case 
of fractured femur with injury to the popliteal, observed the fracture 
no less firmly united in six weeks.* 

(3.) Erysipelas, or phlegmonous abscess, occurring in a fractured 
limb, will generally retard the solidification of the callus. When a 
pupil at Val-de-Grace, I saw, in M. Fleury's ward, a man who had 
fractured one of the phalanges while drunk ; there ensued what were 
then called symptoms of gastritis, which required treatment; after 
this, phlegmonous inflammation declared itself in the vicinity of the 
fracture ; the callus did not begin to form till this had subsided, and 
the bone was not firm till the man had been two months and a half 
in the hospital. 

[Erysipelas being universally recognised as an asthenic disease, in 
the fullest sense of the term, in all its conditions, may it not be to 

* Dupuytren, Des AnAvrysmes qui Compliquent les Fractures; Lecons 
rales, second edition, tome ii, p. 507 ; Norris, loc. cit. 



126 A TREATISE ON FRACTURES. 



f system, of which this is a very plain index, that we 
11 refer the' want of union in the hone? In other words, are not 



the 

inuM 

the erysipelas and the non-union results about equally close of a 
common cause ': And yet a case is quoted from Seerig, by Dr. Nor- 
lia, in which erysipelas seemed to act like a blister in hastening con- 
solidation. Kuklwide gives a similar case in the American Journ. of 
i/. I s : N «•, L835.] 

A ne mil: the causes of non-union connected with the disposition of 
the fragments, have been placed (1) the obliquity of the fracture; 
separation of the fragments ; (3) interposition of bodies be- 
fit,- broken ends ; (4) suppuration, in compound fractures; (5) 
want of nutrition in one of the fragments ; (6) and lastly, some affec- 
tion of the bone, just at the level of the fracture. 

(1.) Dupuytrcn especially has attempted to place in relief, as a 
cause of non-union, the obliquity of the fracture. While in trans- 
verse fractures, said he, the callus is solid enough at the end of forty 
days, because the fragments mutually support one another against 
the action of the muscles, in oblique fractures, on the contrary, the 
fragments only touch by inclined planes, and afford one another no 
purchase ; whence the action of the muscles comes entirely on the 
pro visional callus, which, being weak, yields, permitting displacement 
and overlapping of the broken ends; from which arise pain, shorten- 
ing, deformity, and the false joints so common after fractures of this 
kind. And consequently, Dupuytren would have the treatment of 
oblique fractures continued twice as long as that of transverse, fixing 
its average duration at three months.* 

In support of Dupuytren's ideas, M. A. Bdrard has added that 
the peeudo-artieular surfaces were oblique in nearly all the patients 
in whom surgeons have attempted a cure. I have not seen that this 
obliquity was nearly so common, and the statement is certainly ex- 
ited. But every surgeon must have been struck with the rela- 
tive -lowi i ess of consolidation in oblique fractures as compared with 
which are serrated or transverse. Must we then accept Du- 
puytren's theory, and the yielding character of the provisional callus? 
We know already what we hold as to the callus; and touching the 
question now under discussion, I believe that what most retards the 
union of oblique fractures is the bad arrangement of apparatus, per- 
mitting the fragments not only to overlap, but even to leave one an- 
other ; so that the lymph effused in the interspace is too abundant, 
and the membranous tissue too lax to readily become the seat of cal- 
careous deposit. Sir A. Cooper taught that, to obtain rapid consoli- 
dation, ;i certain degree of pressing together of the fragments was 
necessary. - We see," said he, "that if the ends of the bones are 
separated from each other by muscular action, as occurs sometimes 

* Dupuytrcn, Lemons Orales, second edition, tome i, p. 37. 



A TREATISE ON FRACTURES. 127 

in fractures of the femur, tibia, humerus, ulna, and radius, union 
does not occur ; till the surgeon, by means of a strong leather band 
buckled round the limb, forces the fragments together, thus producing 
the inflammation requisite to the production of bony callus. " * I agree 
entirely in this opinion, and in speaking of fractures of the leg shall 
cite cases of consolidation obtained in less than six weeks by my 
screw-apparatus, which exerts the greatest possible pressure on the 
fractured surfaces. 

(2.) This first alleged cause of non-union blends itself somewhat 
with the second, viz., the separation of the fragments. Transverse 
fractures of the patella are the most common examples of the effects 
of this separation ; here fibrous union is the rule, and bony consoli- 
dation a very rare exception. Such is the case also in fractures of 
the long bones of the extremities. Sir A. Cooper has related three 
cases of fracture, with loss of substance, of the tibia, the fibula re- 
taining its length ; between the separated fragments no bony forma- 
tion occurred. Experiments with similar fractures, in animals, have 
given like results. This law, however, has many exceptions, if one 
may believe observers. Delamotte says that he extracted a portion 
of the tibia four fingers'-breadths long, at about the sixtieth day of 
a fracture of the leg, and that the formation of callus took place per- 
fectly. The period of extraction in this case favors the idea that 
the reparation occurred by means of the periosteum, as in any case 
of necrosis ; but in the next observation, the same surgeon relates 
the history of a recent fracture, in which he removed a portion of the 
cylinder of the tibia five or six inches long, which was replaced, 
without shortening, by solid callus. Gooch says he removed five 
inches of the tibia, Phillips likewise five inches, with equally satis- 
factory results. f Without at all questioning the good faith of these 
surgeons, we may believe that they were deceived, mistaking for 
bony callus a cicatrix of quite another character ; and nothing short 
of careful dissection could demonstrate the reality of such wonders. 
Norris has treated a child twelve years old, from whom he removed 
two inches of the tibia ; the callus formed, but with half an inch 
shortening. This is somewhat more probable ; yet there is still 
some room for doubt. It is actually true that there are in our mu- 
seums several specimens of fragments separated one or two centime- 
tres, which have still been united by solid callus ; but we see that the 
wonder lessens as we view it more closely ; and these results may be 
considered even as ordinary facts. 

(3.) The interposition of a foreign body between the broken ends 
is much more rare. Sometimes the substance comes from without ; 
thus M. A. Berard quotes from Rossi a case in which a ball, lodged 

* See Sir A. Cooper's article on intra-capsular fractures of the cervix 
femoris. 

f Delamotte, TraiU compl. de chirurgze, obs. 79 and 80 ; Norris, loc. cit. 



[28 A TREATISE ON FRACTURES. 

in the medullary canal of the humerus, hindered the union of the 
fracture ; and under such circumstances, it would doubtless be some- 
what absurd to count on the efforts of nature. These have, however, 
Bometimes done a great deal; M. Vogelvanger treated, and cured 
in Bixty-four days, a compound fracture of the femur; the patient 
dying at the end of two years, the autopsy revealed within the mass 
01 callus a bit of iron about two inches and a half in length, about 
halt* of which projected outside of the bone.* I have already spoken 
of tlu 4 jaw broken by a gunshot injury, the callus of which had nu- 
merous grains of shot imbedded in it (see Fig. 16;) and I have 
among my drawings one of a femur fractured by a ball, during the 
three days of July, 1830; the ball lodged between the fragments, as 
is shown by the empty space separating them, while posteriorly they 
are united by a pretty firm callus; the specimen is in the museum 
at Val'de-Grace. 

But most commonly it is by splinters, by muscle, or by effused 
blood that the formation of callus is hindered. Splinters, in a simple 
fracture, are easily enough surrounded by the callus; but in gunshot 
fractures, the importance of extracting them is well known to mili- 
tary surgeons. The interposition of some portion of muscle or of 
aponeurosis has been alleged as a cause of non-union, mainly from 
a case reported by Samuel Cooper. It was that of a woman who 
had a fracture of the humerus several months old, but still ununited, 
when she died of some other affection ; the lower fragment, sharply 
pointed, w r as imbedded in the substance of the biceps muscle, so that 
it could not possibly be disengaged. Dupuytren likewise ascertained, 
by the dissection of a non-consolidated fracture, that the callus was 
hindered from forming by the interposition of muscular fibres. These 
are, however, very rare cases, and the chasm must be very con- 
siderable to prevent the callus from filling it up. M. A. Berard re- 
lates a curious case, which has been communicated to the Anatomical 
Society, and which may serve as a counterpoise to those of S. Cooper 
and Dupuytren. In a clavicle which had sustained a fracture long 
before, the two fragments were seen separated to the distance of an 
inch by the sub-clavius muscle, but united by two bony bridges, be- 
tween which the muscle, itself ossified, was confined. 

An excessive effusion of blood may also hinder the formation of 
callus ; but care must be taken not to mistake one cause for another. 
In the third observation of Dupuytren's Memoir on Aneurisms, al- 
ready cited, the effusion was so considerable that amputation of the 
thigh was deemed necessary; the fracture dated back less than forty 
days, and was already solidified ; but the patient had been almost 
without fever. In the fourth observation, the patient had had con- 
stant fever; the callus did not become solid for more than two 

* Gazette Midicale, 1838, p. 445 



A TREATISE ON FRACTURES. 129 

months. I have before quoted an observation of my own, of a case 
in which the non-union might have been attributed to the numerous 
clots around the fracture, had not the fever and the metastatic ab- 
scesses which carried the patient off exerted a less contestable and 
less contested influence. 

(4.) Suppuration, in Compound Fractures. — Every one knows 
that a fracture with suppuration takes more time to heal than one 
buried among the muscles. The larger and more contused the wound, 
the more abundant the suppuration, and the less ready the formation 
of the callus. Gunshot fractures are the slowest of all in uniting ; 
and next to them come divisions of the bones by cutting instruments ; 
which facts may be attributed, mainly at least, to the abundant 
suppuration which ensues in both. 

Besides suppuration occurring just at the seat of fracture, a simple 
external wound, an ulcer, seems also to weaken, lessen, or interfere 
with the work of consolidation. Duhamel ascertained that in a young 
pigeon with a wounded wing the callus at the fifteenth day was no 
more advanced than at the tenth in a sound bird. 

(5.) Defective nutrition of one of the fragments can hardly be 
alleged except in the case of intra-capsular fractures of the femur 
and of the humerus, of splinters almost entirely stripped of perios- 
teum, or lastly, when the limb is so nearly cut off that the circulation 
only goes on through a very narrow flap of tissue. We need not dwell 
on this very evident cause of non-union, which defies all treatment. 

((3.) Nor shall we discuss at any length diseases of the fractured 
bone. Of course caries, necrosis, or cancer will constitute an ob- 
stacle to consolidation. Hydatids developed in the medullary canal 
had this effect in cases mentioned by Webster, Wickham, and Dupuy- 
tren. A distinction must however be drawn in regard to exostoses. 
Arnott resorted to amputation in a fracture of the tibia seated at an 
exostosis, which was not united at the end of a whole year ; but 
Brodie, having to treat a fractured clavicle under analogous condi- 
tions, saw the callus form as readily as usual.* We see, then, that 
the complication of exostosis need not destroy all hope, and that we 
must be guarded in our prognosis in such cases. 

If, therefore, among all these causes there are some which cannot 
be entirely avoided, some of them may be advantageously combated, 
while if allowed to act they would render the surgeon liable to the 
charge of negligence or of error. 

But those which we have still to study are of a different nature, in 
that the treatment itself gives rise to them in fractures which have 
the best disposition to unite. Such are (1) the abuse of wet dress- 
ings ; (2) the too early application of bandages ; (3) excessively tight 
bandages ; (4) the too prolonged application of bandages ; (5) local 

* Noms, loc. cit. 
9 



180 A TREATISE ON FRACTURES. 

; (6) motion of the fragment* ; (7) the premature use of the 

(l.i It is not only in our own times that the abuse of ivet dressings 
reatment of fractures has been denounced as injurious; Paulus 
i complained of the improper employment of fomentations; 
ma denounced affusions of oil and of hot water during the 
organisation of the callus, because they hinder reparation ; Ames- 
bur v Bays the same of cold lotions; and M. J. Cloquet, among the 
principal causes of local scurvy, speaks of the too prolonged use of 
emollients. 

On the introduction of continued irrigation as a form of wet 
dressing, great hopes were at first excited, particularly in reference 
to compound fractures. But besides other serious dangers, these 
irrigations generally retard consolidation; thus of nine compound 
fractures, the history of which is given by M. Nivet, two only were 
united within the usual time; two required two and a half or three 
and a half months ; two, five and seven months ; one was dismissed 
without union at the one hundred and ninetieth day; and the 
remaining two died.* 

(2.) The premature application of bandages has excited especial 
attention since the general introduction of the immovable apparatus. 
M. Rognetta, having thus treated a fracture of the leg and a frac- 
ture of the thigh in M. Bresalet's ward, had the annoyance of 
seeing them still un-united at the end of three and a half months. 
MM. Nanula and Petrunti, being consulted, attributed this want of 
success partly to the following novel cause. "We may affirm," said 
they, "from our experience, that fractures to which the apparatus is 
applied during the first period unite more slowly than such as are 
at first left free, being confined only during the process of consoli- 
dation. " f The apparatus acted then, according to them, by exercising 
too strong a compression, and thus preventing the inflammation neces- 
sary to solid union. In this point of view a bandage too early applied 
would act just like one applied too tightly; whence, for the sake of 
a clear discussion, we must study the effects of such constriction. 

(3.) The too great pressure of bandages is one of the causes of 
non-union most insisted on by A. Pard; and after him, Wiseman in 
. intecnth century, and Duverney in the eighteenth, agree in 
Baying that nothing hinders so much the formation of callus. This 
U confirmed by experiment; thus, Delahaye having broken the leg 
of a young pigeon, and then compressed the limb tightly between 

• Malgaigne, De Virricjation dans les Maladies Chirurgicales. See also 
M. \i vet's memoir in the Gazette Medicate, 1838, p. 36. 

gnetta, ResvUats des experiences faites a V H6tel-Dieu, etc., Gaz. 
JUddtccUe, L834, p. 257; Nanula and Petrunti, Rtponse d M. Roqnetta, ib. 



A TREATISE OX FRACTURES. 131 

two hollow splints, Duharnel, who assisted at the dissection, tells us 
that at the eighth day there was neither swelling of the periosteum 
nor any disposition toward uniting. Troja obtained the same result 
in dogs, making pressure by means of bandages. Now when we 
examine the first instances of non-union under the treatment by the 
immovable apparatus, we find that besides its too early application, 
its excessive tightness is mentioned, and I incline to the opinion that 
this latter is the fault. It may be answered that this compression 
can hardly be exerted on bones surrounded, like the femur, by a 
mass of muscle; that it is nothing at all in many cases where the 
limb emaciates so as to leave a space between it and the bandage; 
that many false joints are cured by this very means, etc. No reply 
need be made to such objections, which mere theory furnishes against 
every opinion; and for my own part, I consider that pressure is 
injurious in the early stage of a fracture, by hindering the swelling 
of the periosteum and preventing the access of blood to the affected 
part. But it must be confessed, I have several times applied the 
dextrine bandage when the callus was already developed, carefully 
avoiding excessive tightness ; and yet I have several times found con- 
solidation imperfect at the end of the usual time for its occurrence, 
though it afterwards did take place. We must therefore seek some 
other cause. 

(4.) Too prolonged application of the bandage, although less gene- 
rally recognised, exerts no less an influence than too great tightness. 
if. J. Cloquet is perhaps the only author who has given it a few 
words in passing. "The fractured limb," says he, "inclosed in an 
apparatus excluding ah- and light, is affected with a sort of chlorosis ; 
it becomes pale, flaccid, and sometimes slightly cedematous, so that 
the lymphatic fluids seem to predominate in it. These changes are 
much more notable in the lower than the upper extremity; being 
more distant from the centre of the circulation, the former have less 
energy, and the callus in fractures of their bones is produced more 
slowly."* If this statement were strikingly true at a time when 
bandages were not generally put on until after the subsidence of in- 
flammatory symptoms, and were renewed from time to time in the 
course of the treatment, how much more does it apply at present, 
when the limb is usually enveloped in an immovable apparatus from 
the first to the last day! There is no surgeon who, examining a 
broken leg at the thirty-fifth to the fortieth day, and finding the 
fragments still movable, has not been struck with the wasted flesh, 
and the scaly and dead appearance of the epidermis ; while toward 
the heel, the skin, puffed with oedema, is pale and blanched. Con- 
solidation is not therefore yet despaired of, but it requires a long 

* J. Cloquet, Du scorbut qui se manifeste d'une manure locale pendant le 
traitement des fractures, Archiv. de M6decine, tome i, p. 470. 



182 A TREATISE ON FRACTURES. 

time for its accomplishment; and why resort to causes often merely 
imaginary, when atony of the limb is present? 

Now if to thifl powerful cause arc joined others; if we have to 
subjects enfeebled by age, previous disease, loss of blood, or 
insufficient diet ; when the air is cold and insalubrious, as in autumn 
or in a rainy winter, and especially if the use of emollients is con- 
tinued till the bandages exhale a mouldy smell, then the affection 
becomes more serious, and we see coming on all the symptoms of 
what i> called by M. J. Cloquet local scurvy. We shall not attempt 
to improve upon the description, given as follows by his master- 
hand. 

" The limb seems to lose its temperature, the skin assumes a dull, 
pale white color, swells, and softens. The epidermis rises and peels 
off; sometimes it forms phlyctense, full of a puriform or slightly 
viscid liquid; the true skin below seems moist and swollen; the 
hairs fall off or come away with the epidermis, as happens in the 
skins of animals when they are macerated. If the fracture is at- 
tended with a wound, the granulations swell, become softish, dark- 
red, discharging only an ichorous pus, and bleeding at the slightest 
touch. Soon the limb is covered with ecchymoses, which seem 
usually to begin about those hair-bulbs which still retain their place; 
these ecchymoses spread more and more, sometimes becoming very 
large. The process of consolidation is arrested ; the fragments still 
present some mobility when their union should be complete. Some- 
times a bloody exudation occurs at several points of the softened 
skin. While these local symptoms are manifested, the general con- 
dition of system seems in many cases unaffected ; the gums are firm, 
not swollen or bleeding ; the appetite remains good, digestion goes 
on well, the sleep is undisturbed, and the mind cheerful, except that 
the patients are wearied by the long duration of the treatment, and 
chagrined that their fractures do not become united." 

M. J. Cloquet has twice had an opportunity of ascertaining by 
dissection the state of the affected parts. The first time, the subject 
was a robust street-porter, fifty-five years of age, suddenly carried off 
by an attack of ileus, after having been seven months under treatment 
for a fracture of the right leg. The local scurvy had shown itself at 
about the second month, developing itself more and more ; still, the rest 
of the economy was unaffected, and two days before his death, his 
genera] health was in a satisfactory state. At the autopsy, the skin 
covering the limb, besides being almost entirely deprived of hair and 
of epidermis, seemed soft, easily torn, and covered with very numer- 
ous blackish and violaceous ecchymoses ; similar ecchymoses were 
Been in the subcutaneous and intermuscular areolar tissue; the mus- 
cle- were; pale, flaccid, softened, gelatinous, and displayed here and 
there in their substance considerable effusions of dark fluid blood; 
the bones at the seat of fracture showed no trace of consolidation or 



A TREATISE ON FRACTURES. 133 

of tumefaction; only the compact tissue seemed to have become some- 
what spongy, and infiltrated largely with black and viscid blood. 
The periosteum above and below the fracture was detached and 
raised up by the same liquid, which also formed ecchymoses within 
the medullary tissue ; the latter was gelatinous, reddish, and nearly 
liquefied. Other ecchymoses infiltrated the ligaments about the knee 
and foot, and the soft parts about the lower end of the thigh; higher 
up, the skin, muscles, and other organs, presented no such appear- 
ances. Similar lesions were observed in a woman forty years old, of 
feeble constitution, who died eight days after the supervention of 
typhoid fever, having been six months under treatment for fracture 
of the right leg. In her, consolidation had apparently begun toward 
the second month; but fifteen or twenty days later there was the 
most perfect mobility of the fragments, and symptoms of local scurvy 
were evident in the affected limb. 

I believe we must distinguish in this affection two quite distinct 
degrees; one very common, for the production of which a too pro- 
longed application of the bandages will suffice, and which is charac- 
terised by detachment of the epidermis, oedema, and paleness of the 
skin, sometimes with the formation of phlyctenae ; the other much 
rarer, requiring the conjunction of other unfavorable conditions, and 
manifesting itself by ecchymoses. When thus advanced, the scurvy 
can hardly remain a merely local disorder, but tends to become con- 
stitutional, as seen by M. J. Cloquet in several of his patients. 

(6.) Movements of 'the fragments, whether due to the patient's 
restlessness, to some defect in the apparatus used, or to any other 
cause, is the obstacle which most directly interferes with union. 
This fact has never been contradicted, and its mere enunciation will 
in great measure suffice; it may however be added that the majority 
of pseudarthroses occur in the humerus and femur, the two bones 
least readily subjected to restraint; and that of forty-four cases in 
which the causes of the condition were investigated, Norris found 
that movement of the broken ends was clearly made out in twenty- 
two cases, and strongly suspected in several others. 

(7.) Lastly, the premature use of the limb, directly causing motion 
of the fragments, acts in the same way; and it is chiefly in oblique 
fractures, or in those attended with notable overlapping, that surgeons 
make this mistake. Nothing is more common than to see an oblique 
fracture of the leg, apparently firm, give way under the patient's 
weight, and overlap or bend, as the result of premature movement. 

Such are the conditions hitherto recognised as predisposing or de- 
termining causes of the non-union of fractures. As several of them 
have long remained obscure, it explains how the writers best entitled to 
authority on this subject, MM. A. BeVard and Norris, still admit the 
occurrence of cases in which false joints are produced without any 
• appreciable cause, and which must be referred to idiosyncrasy. The 



184 A TREATISE ON FRACTURES. 

more I examine this question, the less am I inclined to adopt this 
idea. Divisions of the .soft parts cicatrise with more or less facility 
in different individuals; but there has never been seen one which 
obstinately refused ko heal merely because of an idiosyncrasy, and 
there ifl no reason why the bones should be exempt from a law com- 
mon to all the other tissues. I have read accounts of pseudarthroses 
occurring, it is Baid, in young, healthy subjects, submitted to treat- 
meni undoubtedly irreproachable; this last point, the one whose de- 
monstration is most necessary, is one of those which are least posi- 
tiwlv proved. And is it not a subject calling for reflection, this 
preference of pseudarthrosis for attacking the youngest and heartiest 
male subjects? Amesbury was likewise struck with this; of ninety 
oases of non-union which he had seen, but three were of decidedly bad 
constitution ; another had been exhausted by cholera during the early 
period of the fracture; add to this number two pregnant women, and 
the remaining eighty-four all enjoyed sound and robust constitutions. 
lie considers that in these latter the cause of the non-union was 
purely local, and that in nearly all, the incomplete apposition and the 
mobility of the fragments were to blame. The merely local causes 
are. as we have seen, much more numerous; but I firmly believe that 
when union is deficient, it is generally the treatment that is in fault. 

This etiology would not however be complete, were we to pass over 
one of the most curious phenomena of this whole subject, called by 
some the absorption, by others the softening [ramollissement] of the 
callus. The first instances of this were observed in scorbutic pa- 
tients. Mead relates the case of a sailor who, having broken his 
clavicle, was sufficiently cured by the end of one month to use his 
arm just as before the injury; but three months later, in hanging by 
his arm, the fragment separated, and the callus became just as at 
the first. At the same time, scorbutic symptoms appeared, delaying 
any effort at consolidation; and it was not till the end of six months, 
ami after the cure of the scurvy, that the callus again became firm. 
A nearly similar case is mentioned in Lord Anson's Voyages, and 
Dr. Budd has seen a third. 

Alter scurvy come severe fevers. Lemaire saw, in 1700, at the 
military hospital in Strasbourg, a soldier who had had a fracture of 
the tibia thoroughly united, and in whom, eight months afterwards, 
the callus gradually disappeared during an attack of fever, to form 
again after his recovery. A. Bonn likewise saw, in an old man, a 
nearly completed callus disappear during a fever with inflammation 
and gangrene, which proved fatal. In another observation published 
bv Mantell, a violent fever destroyed the callus of a fracture of the 
eeral weeks after its complete formation, in a young man of 
seventeen; the fever being cured, the callus was thrown out anew, 
hut the limb was much deformed. Hitherto there has been room for 
doubt whether the bony callus was merely reduced again to a fibrous 



A TREATISE ON FRACTURES. 135 

condition, or disappeared entirely; but an observation of Schilling's 
shows that the word ramollissement is not applicable, at least in all 
cases. A man had a fracture of the femur, which was so well con- 
solidated that he could bear some weight on the limb. He had an at- 
tack of abdominal typhus; at the tenth day of the disease, all traces 
of the callus had disappeared ; and death ensuing six days after, the 
autopsy showed the fragments bleeding as in a recent fracture, and 
enveloped in a sort of membranous sac containing a little dark liquid 
blood.* 

Erysipelas seems sometimes to have the same effect. I published, 
in 1830, in the Lancette francaise, the history of a fracture of the 
leg, consolidated at the fifty-ninth day ; a month later, erysipelas 
attacked the whole leg and destroyed the callus, a new formation of 
which required two months. This circumstance struck me forcibly, 
and led me to look up similar instances; and I established it as an 
almost invariable law, that erysipelas occurring in a broken limb not 
only retards consolidation, but causes it to go bach. I have, indeed, 
seen a statement by S. Cooper that Langenbeck saw the same thing 
in several patients ; Dupuytren gives a case ; Wardrop two ; Wright 
another; and since then others have been reported. f But it should 
be stated that it is not always so ; when the callus is of old standing, 
it resists wonderfully. A man aged 47 was admitted into my wards 
for a fracture of the leg, badly consolidated, and followed by stiffness 
of the joints. He was attacked by very severe erysipelas, involving 
the whole limb, and lasting seven days ; the callus however lost none 
of its solidity. 

Probably to these causes it will be proper hereafter to add others. 
Kirkbride has given us an account of a small ulcer, seated just over 
a recently united fracture of the leg, which became gangrenous, and 
led to the absorption of the callus. J Dr. Penel saw the callus dis- 
appear twice successively in the same subject, with no other apprecia- 
ble symptom than the deposit of a large quantity of phosphate of 
lime in the urine ; the second time nitric acid was given in lemonade, 
the urine became clear, and the fracture united without any further 
relapse. Lastly, in Norris's memoir there is recorded a case much 
more singular, and probably unique. A young man of eighteen 
broke his humerus at about the middle. Consolidation progressed 
favorably, until the broken ends were separated by another fall. 
From that time, not only was there no union, but absorption began 

* Reisseissen, Diss, de Articulationibus Analogis, Prces. J. Sahmann ; 
Argentor., 1718? A. Bonn, Tliesaur. ossium Hov.,-p. 187; Norris, loc. cit. 

t See Malgaigne, Lancette francaise, 1830, p. 217 ; Dupuytren, M6m. sur la 
fract. du p6roii6, obs. 4; Wardrop, Obs. sur V usage du stton dans les fract. 
non-consol. ; Melange de chirurgie Uranglre, tome i ; Wright, Reflexions sur 
la reunion des os fracture's, etc., Journal des Progres, tome xv. 

% American Journal of the Medical Sciences, Feb., 1835. 



13() A TREATISE ON FRACTURES. 

in each fragment, and went on until, without any ulceration or 
wound, the humerus entirely disappeared; so that, eighteen years 
afterwards, no trace of it could be detected.* 

There being so many obstacles to bony union, the wonder is that 
false joints are BO rare. Many of these causes exhaust their action 
in retarding consolidation, without absolutely preventing it; it is 
hard to say, unless five or six months have elapsed since the occur- 
rence vi' the injury, whether we have to deal with a case of mere 
slow union, or with one of actual pseudarthrosis. This difficulty is 
best resolved by dissection. 

Norris distinguishes four varieties of false joint: 

(1.) The fragments are surrounded by a cartilaginous tumor, in 
which ossification is not yet begun ; there is rather slow T ness than 
absence of union, to produce which, rest and compression will gene- 
rally suffice. An important circumstance in diagnosis is the pain 
caused by any sudden movement impressed on the limb. 

(2.) The fragments are entirely separate, very movable under 
the' skin, and their ends seem to have undergone a sort of atrophy. 
The limb is much shortened, and hangs useless. 

(3.) Union is effected by means of a fibrous tissue of greater or 
less length, strength, and thickness; sometimes holding the frag- 
ments close together, sometimes allowing very free flexion. The 
fragments are often more or less rounded off by absorption ; some- 
times again they remain pointed; but the medullary canal is always 
obliterated at their extremities. 

(4.) Lastly, there may be formed a true diarthrosis, constituted 
by a dense and firm fibrous capsule, smooth internally, and contain- 
ing a liquid like synovia. The ends of the bone are rounded and 
polished, sometimes eburnated; and sometimes covered over by 
cartilages and a synovial membrane. 

Of these four varieties, the third is by far the most common. The 
first Bhould hardly be admitted; the second is quite rare; the fourth 
perhaps still more so, Eoyer and others having actually doubted its 
reality. The observation published by Duverney and Sylvestre 
wants exactly those details which are most essential ; and it is always 
hard to judge from a dried specimen whether or not there has been 
a synovial membrane. But other and better substantiated cases have 
established beyond a doubt the existence of these accidental diar- 
throses ; A. Key has seen one in the spinous process of a vertebra ; 
Kuhnholtz in the femur; Sir E. Home, Cruveilhier, and Howship 
in the humcrus.f They seem to occur much more frequently in ani- 

* Norris, loc. cit. 

t Sec A. Cey'a observation in Sir A. Cooper's Treatise on Dislocations and 

Fractures of the Joints, art. Injuries of the Spine, [p. 386, Am. ed., 1825;] 

Cnhnholtz, Consid. but lesfausses articulations ; Journ. complem., tome iii, p. 

3irB. Home, Transactions of the Society for Improvement of Med. and 



A TREATISE ON FRACTURES. 137 

mals than in man ; indeed, of nine false joints obtained by M. Bres- 
chet in his experiments on dogs, six displayed an articular cavity. 
I have myself obtained two in an old dog in which I broke the ra- 
dius and ulna ; the capsules were very thick ; the ends of the bones 
were covered with a rough, soft, white layer, like articular cartilage 
deprived of its polish and made fibrous. 

The distinction between purely fibrous union and pseudo-diarthro- 
sis has much more importance anatomically than practically ; in the 
living subject the differential diagnosis is generally impossible. It 
would be necessary, in order to make a diarthrosis probable, to hear 
the sound of rubbing of the two articular surfaces against one an- 
other ; it will easily be understood, moreover, that this diagnosis 
could be much more clearly made out if the articular cavity should 
contain thirty or forty floating nodules of cartilages, as in Sir E. 
Home's patient. 

But, I repeat, this has not any great value in a therapeutical point 
of view, which is the principal one to the surgeon. In practice, 
pseudarthroses may be divided into three classes, very different from 
those just described. 

(1.*) Either the fragments appear absolutely independent of one 
another, floating, as it were, among the tissues. 

(2.) Or, they are joined by the fractured surfaces, without notable 
overlapping. 

(3.) Or, lastly, the overlapping has separated the surfaces, and 
the fragments touch each other only laterally. 

In the two latter cases, there may be again three principal condi- 
tions: sometimes the fragments are strongly jammed against one an- 
other, so as not even to allow of the introduction of a needle ; some- 
times they are much looser, and therefore more movable ; sometimes, 
lastly, their extremities are enveloped in "accidental" deposits of 
bone, evidencing the efforts of nature to bring about union. It is 
concerning these conditions, rather than the fibrous or diarthrodial 
structure of the false joint, that we should be informed in order to 
ascertain the indications in each case. 



ARTICLE V. 

DIAGNOSIS. 

This subject has been to a considerable extent treated of in the 
study of the varieties of fractures and of their general semeiology ; 
it will therefore suffice to recall here, in a rapid resume, what degree 

Surg. Knov;ledge, London, 1798, p. 235 ; Howship, On the Formation of New 
Joints ; Med. Chir. Transactions, vol. viii, p. 513. 



138 A TREATISE ON FRACTURES. 

of confidence the Burgeon should accord to the different sets of symp- 
toms; l»ut we most also point out some new resources to which we 
can apply when the ordinary signs are ohscurc. 

The Bymptoms of fracture are rational or sensible. The rational 
arc the iiack heard by the patient, the pain, the loss of power, the 
contusion, the primary or secondary swelling ; but they can never, 
even when all present at once, afford ground for a positive diagnosis. 

The Bensible or physical are, preternatural mobility, deformity, 
and crepitus. I have nothing more to add to what has been already 
said concerning the first and last of these ; but the different varieties 
of deformity present several sources of deception against which we 
must be on our guard. Everything depends on exact measurement, 
for the avoidance of error; but this measurement comprehends seve- 
ral different processes. 

Sometimes it is important to ascertain the increase in thickness of 
a limb. We may then compare, by means of a graduated tape, the 
circumference of the sound limb with that of the unsound one, taking 
care to observe the same level in both, and first of all assuring our- 
selves that no previous affection has given rise to any inequality in 
their volume. This mode cannot, however, be adopted in all regions 
of the body ; for instance, in some fractures of the fibula where we 
would ascertain the separation of the malleoli, it is better to resort 
to M. Mayor's compasses, which do not indicate the circumference, 
but only the diameter. 

The compasses themselves are insufficient when the bones are com- 
pletely masked by a considerable swelling of the soft parts. At an 
early period of the fracture, it is better to wait till the swelling sub- 
sides; but the diagnosis often remains still obscure; and the surgeon, 
uncertain whether he has to deal with a fracture or a luxation, is 
equally afraid of acting or remaining idle. I then make use, with 
advantage, of needles inserted as far as to the bones, in each limb, 
s<» as to compare the two. Sometimes one needle is sufficient to en- 
able us to judge of the relative depth of the fragments. Sometimes, 
again, two are necessary, with the compasses applied over them, to 
judge of the amount of separation of two bones, as at the malleoli. 
We may make use either of acupuncture needles, of ordinary nee- 
dles, or of mere pins ; they are pushed at once down to the bone, the 
depth of this beneath the surface is carefully remarked, and they are 
then withdrawn as quickly as they were entered. Usually not a drop 
of blood escapes, and I have never seen any bad result, however 
Blight. When pins are* used, a simple means of marking the depth 
to which they have gone consists in nipping them with scissors at 
the level of the epidermis; we thus make a double notch which can 
hardly be effaced. Needles passed to and fro over the broken ends 
may also give useful information as to their position, form, angles, 
and the presence or absence of splinters; just as sounding makes 



A TREATISE ON FRACTURES. 139 

known to the mariner the nature, etc. of the bottom over which he 
sails. 

By these means we may with ease and accuracy determine the 
reality and extent of transverse displacement ; angular displacement 
sometimes needs a more strict mode of measurement. For this purpose 
I use a sheet of paper, applying its edge upon the limb so as to re- 
present its vertical axis. At the spot where this axis changes its 
direction, the paper is so folded, more or less, as exactly to follow it; 
the salient angle resulting will necessarily show exactly the entering 
one formed by the fragments. It remains to find the value of this 
angle; a quadrant would give it accurately, but for greater simpli- 
city we may proceed as follows: a sheet of paper folded in four 
makes a right angle, or 90°; folding again one of the sides, we have 
an angle of 45°; adding this angle of 45° to the unchanged right 
angle, we have one of 135°, and so on. Applying now this extem- 
pore quadrant to the already ascertained angle of the fracture, we 
have, without trouble or loss of time, as close an estimate as possible. 

For displacement by rotation, we may in the same way extem- 
porise a square; but generally it suffices to compare the two limbs, 
or to study the relative position of some natural prominences. Thus, 
the leg being in the horizontal position, the inner edge of the great 
toe should correspond to that of the patella; if it is turned inward 
or outward, there is rotary displacement one way or the other. 

There remains lastly overlapping, sometimes evident at the first 
glance, but frequently requiring confirmation by measuring the length 
of the limb. This measurement calls for certain precautions varying 
with different cases. First of all we must have certain fixed points, 
where we may firmly apply the tape, without danger of moving it to 
one side or the other. These are usually bony prominences where 
we press the tape with the nail ; thus in the arm, the posterior angle 
of the acromion, the epicondyle, [the external condyle of English 
and American anatomists,] the styloid processes: so also in the lower 
extremity, the iliac spine, the edge of the femoral or tibial condyles, 
the head of the fibula, the malleoli. For instance, to get the length 
of the extended thigh and leg, I place one end of the tape on the 
anterior superior spine of the ilium, fixing it here with the edge of 
the nail turned upward and pressing against the under face of the 
spine; and I fasten the other end below the external malleolus by 
pressing it likewise with the nail. In the arm, I place one nail 
under the posterior angle of the acromion, the other against the 
upper edge of the epicondyle. 

A second precaution no less important, is to keep the two limbs in 
the same condition as regards extension, abduction, obliquity, etc. 
Thus the lower extremities should be kept parallel, as much as pos- 
sible, and the iliac spines at the same transverse level. For greater 
accuracy, I have a tape stretched across from one spine to the other, 



Ill) A TREATISE ON FRACTURES. 

Mid fastened by fche pressure of an assistant's thumb below each 
Bpine; from the middle of this tape — a point in the median line of 
tin' body — I let fall another tape perpendicularly, as far as the 
heels, which arc pieced at equal distances from it. If by reason of 
any lesion whatever, one of the limbs is persistently abducted or ad- 
dueted, and cannot be brought parallel with the other, I place the 
latter in a corresponding position of abduction or adduction, taking 
the last-mentioned tape as a guide. Extension or flexion must like- 
• exactly the same, as well as rotation; and besides, all this, it 
is important that the measuring tape should not be turned aside by 
any prominence or swelling which may exist on one side only. 

In the upper extremity, the surgeon should follow the same rules, 
although this seems to be hardly noticed by the majority of observers. 
I have never seen care taken, in measuring the arm from the acro- 
mion, to place the two scapulae in the same position, the angles of 
the two acromion processes in the same transverse plane, the two 
elbows at the same distance from the median line; I myself long 
neglected these precautions, until at last I learned their necessity. 
Not only in fractures, but in the diagnosis of luxations and of affec- 
tions of the joints, does measurement lead us to true or false con- 
clusions according as it is well or badly made. This is too evident 
to be further insisted on ; we shall moreover have to recur to it in 
speaking of particular fractures. 



ARTICLE VI. 

PROGNOSIS. 

Our prognosis should have reference to several points, viz., the 
favorable or unfavorable termination of the case; its simple or com- 
plicated course; the influence of each complication; the duration of 
the treatment; and lastly the result as to the functions of the limb. 

A simple, recent fracture, the fragments remaining or being re- 
placed in perfect contact, will unite well, without bad symptoms, 
without deformity, without any detriment to the functions of the 
limb, in a space of time easily estimated, varying only according to 
the hone fractured and the age of the patient. Thirty days are re- 
quired, for instance, for a fracture of the clavicle in an adult or an 
old man; in a little child, fifteen or twenty will suflice. 

P>ur ]f the Fracture has already existed two or three weeks, and 
still remains as movable as on the first day, the result is more doubt- 
ful. It may still unite, especially if the mobility is due to the want 
of suitable treatment ; but the time requisite will be longer; it may 
not unite at all, and hence our prognosis should be a guarded one. 

In a subject affected with any acute disease we are to expect a 



A TREATISE ON FRACTURES. 141 

slow consolidation, as well as in certain diatheses ; and here the incon- 
stancy of the results should make us careful in making statements. 
So also in a pregnant woman, we should not be too decided ; prog- 
nosis is essentially the art of foreseeing everything. 

If, in a simple fracture, the broken ends remain nearly in apposi- 
tion, the prognosis is almost as favorable as when they are quite so ; 
only there will remain some little deformity, and a somewhat longer 
time will be necessary to complete their union. 

If the fracture is very oblique, with a tendency to transverse dis- 
placement and more or less overlapping, the time required will be at 
least half as long again as in ordinary cases. 

If the fragments overlap so as only to touch laterally, the callus 
will need twice the usual time to solidify. A simple fracture, with 
splinters and overlapping, takes still longer, and, besides the shorten- 
ing, leaves behind it a large and badly-formed callus. If the frac- 
ture is double in a single bone, with overlapping of all three frag- 
ments, the shortening and deformity are still greater, and the 
consolidation still slower. 

All overlapping tends to cause shortening of the bone ; and the 
cases in which it can be corrected by art are only rare exceptions. 

Erysipelas in the limb retards the callus. It may even destroy 
callus already formed ; but this rarely fails to be reproduced sub- 
sequently. 

Suppuration, even if unconnected with the fracture, retards the 
callus. 

Every fracture with an external wound is serious. The gravity 
of the case is less in the small bones, greater in the large ; it is also 
modified by the size and character of the wound. There is some 
reason to fear, if the wound suppurates, that consolidation will be at 
least much retarded ; or purulent deposits may take place in the 
limb, rendering amputation necessary. 

If one of the fragments project out of the wound, the prognosis 
becomes still more serious. 

The more clean and regular a fracture attended with an external 
wound, the more encouraging is our prognosis. The more it is com- 
plicated with splinters and comminuted portions, the greater is the 
danger. Gunshot-fractures are the most serious of all ; in the tibia 
and femur, they nearly always call for amputation. 

There is one exception to the preceding rule: a simple fracture by 
counter-stroke, when the shock has been violent enough to drive one 
fragment through the skin, is more apt to be followed by serious and 
even fatal symptoms than a splintered fracture by direct violence, 
unless in the latter the soft parts should be excessively torn or 
contused. 

A fracture attended with suppuration requires, cceteris paribus, at 
least thrice the time for consolidation that a simple fracture would ; 



[42 A TREATISE ON FRACTURES. 

but tlii- term may be extended from three months to a year, or even 
more. 

In all eases a fracture at the middle of a bone is less dangerous 
than one toward either extremity; an intra-articular fracture is the 
worst "1" all. 

Every simple intra-articular fracture tends to unite by fibrous tis- 
gue; bony union is the exception. 

Every intra-articular fracture with an external wound threatens 
tli.' joint with true or false anchylosis. In the large joints the symp- 
toms frequently call sooner or later for amputation; in the knee, 
though the wound may not be very large, or lacerated, immediate 
amputation is the rule. 

The longer a fractured limb has remained at rest, the more diffi- 
cult is it to overcome the stiffening of the joints. If there is also a 
certain degree of irritation about or within the joint itself, owing to 
tlu- Beat of the fracture, the stiffening will be greater and more 
stubborn. 

In even the simplest intra-articular fractures, we should beware of 
premising that the limb will recover its full power and motion. This 
may occur, but only exceptionally. 

AVI i en a fracture has lasted six months without consolidating, it 
would be unwise to affirm that it will do so under any treatment we 
may adopt. 

On the whole, then, to form a judicious prognosis, the surgeon 
should take into account the age of the patient, the sex, the state 
of strength or debility, of health or sickness ; the circumstances of 
the fracture, as regards its seat, its nature, its recent or ancient 
date, its complications ; and lastly, the plan of treatment already 
pursued, as well as that proposed for the future. 



ARTICLE VII. 

TREATMENT. 

Tin: treatment of fractures consists, generally speaking, in the 
fulfilment of two principal indications: to reduce the broken ends, 
and to keep them in place until consolidation is complete. There 
nit cases which do not call for reduction, where the relative 
position <>f the fragments is unchanged, and we have only to main- 
tain them sufficiently at rest. But this apparent simplicity conceals 
numerous complications; besides the first attentions required by the 
patient, the mere reduction gives rise to various important questions 
as to tlir position to be given to the limb, the means of effecting the 
object, and the precise time to employ them. Again, as to retaining 
the fragments in place, four great problems are to be solved: the 



A TREATISE ON FRACTURES. 143 

apparatus to be used, the time at which to apply it, the time to renew 
it, — if, indeed, it is to be renewed at all, — the time when motion is 
to be impressed upon the limb ; lastly, during the time requisite for 
consolidation, as well as subsequently, the surgeon must be on the 
watch, so as to prevent or correct any symptoms which may arise. 
All these difficulties, met with in the treatment of simple fractures, 
are still more urgent in those which are complicated; and, after all, 
in more unfavorable cases, we may have to remedy either of these 
three troublesome results of fracture : anchylosis, deformity, and 
non-union. 

§ I. — Of the First Attentions to the Patient. 

"When a person sustains a fracture of the upper extremity, he can 
easily go himself to find a surgeon ; the injured member being sup- 
ported by the hand of the sound side, or at most requiring merely a 
sling. 

It is not so when the lower extremity is involved. The patient 
must be raised up and carried, and his clothes must be removed ; all 
which is very painful unless skilfully done. A. Pare, just as he was 
going on board a boat, had his left leg broken by a kick from a horse. 
He says : 

"Ayant recu le coup, et craignant que le cheual ne ruast derechef, 
ie desmarchay vn pas: mais soudain, tombant en terre, les os ja frac- 
tures sortirent hors, et rompirent la chair, la chausse et la botte, 
dont ie sentis telle douleur qu'il est possible a homme d'endurer. . . 
Soudain fus porte' dans le bateau pour passer de l'autre part pour 
me faire panser. Mais le branlement d'iceluy me cuida faire mourir, 
pourceque 1' extremity des os rompus frayoit contre la chair, et ceux 
qui me portoient n'y pouuoient clonner ordre. Estant hors, fus porte 
en vne maison du village, auec plus grancle douleur que ie n'auois 
endure au bateau ; car vn me tenoit le corps, vn autre la iambe, 
l'autre le pied ; et en cheminant, l'vn haussoit a senestre, l'autre 
baissoit a dextre. Enfin, toutesfois, on me posa sur vn lit pour vn 
peu reprendre mon haleine, ou, pendant que mon appareil se faisoit, 
ie me feis essuyer tout le corps pourceque i'estois en vne sueur 
vniuerselle; et si on m'eust iette' en l'eau, ie n'eusse este plus 
mouille." * 

* ["Having received the blow, and dreading lest the horse should repeat it, 
I made a step backward ; but suddenly falling to the ground, the broken bones 
stuck out, piercing the flesh, the stocking, and the boot ; from which I felt the 
most intolerable pain. . . . Yery soon I was carried to the boat, to be taken to 
the other side, that I might be dressed. But the jolting thus caused nearly 
killed me, since the broken ends of the bones tore the flesh, and those who bore 
me were unable to fix them. On landing, I was removed to a house in the vil- 
lage, with even greater suffering than I had endured in the boat ; for one car- 



144 A TREATISE ON FRACTURES. 

This sad picture is too often repeated on the field of battle, where 
tli,« wounded must be set astride of guns, raised by their garments, 
or rolled up, BO to speak, in a cloak, to be dragged rather than car- 
ried. How often, cries Percy, have we seen officers and soldiers 
thus carried Bometimes half a league from the field! and it must be 
oonfessed that, but for this increase of suffering, many brave men 
would -till baye retained life and limb.* 

For in v own part, I regard these jolts in carrying as one of the 
chief causes of the spasmodic startings of the muscles, and of the 
extensive inflammation so often supervening on complicated fractures. 
It is therefore important to dwell on this point; principiis obsta. 

In cities and towns it is but rarely that a hand-barrow or a litter 
cannot be found, on which to lay the patient. In Paris, the litter 
used consists of an oblong frame on four legs, with a bottom made 
of stout linen ; the part supporting the lower limbs is horizontal ; 
the remainder, corresponding to the trunk and head, forms an inclined 
plane. On the frame are placed iron rings, to which may be fas- 
tened a sheet for protecting the sufferer from the air, light, etc. For 
the first removal of a patient, there is really nothing simpler or 
better. 

But an army could not carry a sufficient number of such litters ; 
something at once of simpler form and more portable must be de-» 
vised. We made use in Poland of the litter of Goercke, consisting 
of two long and solid wooden bars, each bearing an iron branch about 
two feet long, to be fixed in a corresponding tenon in the other ; con- 
stituting thus the frame. The bottom was formed of an oblong 
piece of strong ticking, having at its longer edges wide hems, within 
which the bars could be passed. Lastly, braces were adjusted to the 
handles, to go over the shoulders of the bearers. 

At first sight it would appear still simpler to fix the ticking per- 
manently to the bars, by wrapping it around them ; the litter would 
take up no more room, and would be more readily set up. But the 
cloth when so fixed is soon worn by the rubbing, or rots by exposure 
to rain and dirt; so that the greater apparent simplicity would involve 
greater trouble in preservation. 

Even as it is, Goercke's litter is but of limited use. Suppose a 
battle which has been expected, and time given to arrange every- 
thing; those litters are at the ambulance, awaiting bearers. The 
wounded fall in the ranks; commonly, there are only their comrades 
to remove them; and there is no time for them to go to the ambu- 

ried my body, another my leg, another my foot; and in walking along they did 
DOl keep in Btep. At length, however, I was laid on a bed, to take breath ; and 
here, while the dressings were in preparation, I caused them to wipe my whole 
body, being in a perspiration all over; had I been plunged into water, I should 
not have been more thoroughly wetted."] 
f Hietoire de In Vie ct des Ouvrages de Percy, par Laurent, p. 381. 



A TREATISE ON FRACTURES. 145 

lance for the litters. But on a sudden alarm, in a hasty skirmish, 
the litters lie in the wagons, there being no time to take them out. 
They are therefore really useful only after the action, in collecting 
the wounded on the field. 

Percy solved the problem by instituting companies of bearers. 
Every man was provided with a fir-tree pole six feet long, which could 
be used at need as a weapon, having an iron point ; this was the 
side-piece of the litter ; every man carried also upon his knapsack a 
cross-piece of walnut, bored at each end with a round hole through 
which to pass the side-piece, and supported on two legs, so as to 
raise the litter about ten inches from the ground. The cloth, carried 
like a girdle or scarf, had two wide hems like those of Goercke's.* 

Percy's plan was adopted by a decree of 1813 ; political events, 
however, prevented its being carried into execution. But I dare say 
that every military surgeon who has been present at serious actions 
would recognise its importance, and the fact that the medical service 
of an army cannot be properly insured without an organisation of 
this kind. 

Too often, moreover, whether in civil or military practice, the 
surgeon is without any convenient means of transport ; he must then 
extemporise one. M. Mayor has pointed out how with poles, lad- 
ders, or boards, connected by nails or cords, covered with a mattress, 
or with hay or straw, one might make on occasion quite a convenient 
litter. f Percival Pott had a similar accident to that of A. Pare*; 
falling from a horse in the street, in London, he broke his leg, and 
the jagged end of the bone pierced the skin. The experienced sur- 
geon at once sent for two sedan-chair-men with their poles, and 
waited patiently, stretched upon the pavement, although it was in 
the midst of January. When they arrived, he purchased a door, 
and made them nail their poles to it; and was thus carried a long 
distance, to his own home.J Pott recovered without any bad symp- 
tom; Pare suffered from violent startings of the limbs, and from an 
abscess of long duration. 

I cannot omit noticing here a very just remark of Earle's ; it is 
that in such cases we too often make use of a carriage, which always 
aggravates the pain, by the jolting, the necessarily confined posture, 
and the difficulty of getting in and out. 

To raise the patient and place him on the litter, the easiest way is 
this : a strong man, standing on the sound side, puts one arm round 
the patient's chest, and the other hand under the pelvis, while the 
patient's arm is placed around his neck. If the patient is very 
heavy, it needs a special assistant to support the pelvis, and in all 

* Eistoire de Percy, par Laurent, p. 379. 
i Mayor, Fragments de Chirurgie Populaire, p. 35. 

% Histoire succincte de la vie de P. Pott, par Earle ; Trad, franc, des oeuvres 
de Pott, tome iii, p. 8. 

10 



|46 A TREATISE OX FRACTURES. 

should support the sound limb. Two others sustain 
the broken limb by its two extremities, taking care gently to extend 
it, and to keep it* in the straight position. At a given signal, the 
patient ia raised, and the litter slipped under him, when he may be 
1 upon it. In the same way he may be transferred from the 
litter to hifl bed, or from one bed to another. 

The bearers should be as nearly as possible of the same height. If 
one is taller than another, the tall one should be placed at the patient's 
not to have the weight of the body pressing on the broken 
limb. For the same reason, in going up a slope, or a staircase, the 
feet should be foremost, and the reverse in descending. Dupuytren 
adopted, at the Hotel-Dieu, a measure of manifest utility ; it was to 
use the lower story for fractures, to obviate the inconvenience of 
carrying them up to the higher ones. 

[At the Pennsylvania Hospital, a large hoisting machine is em- 
ployed, with a platform capable of accommodating a bed and several 
ats; on it severe cases of all kinds are constantly and easily 
raised to the second and third stories.] 

It is well also to regulate the step of the bearers. The fewest 
possible jars will be caused, when they keep step; in order to which 
they must set out right. 

The patient being brought close to his bed, his clothes must be 
removed. To do this, the broken limb is steadied; those garments 
are taken off which give little difficulty in so doing; those covering 
the fracture itself should be ripped or cut off with scissors; then the 
bed being made ready, the covers thrown off, and the apparatus ar- 
ranged on the sheet, the patient is carefully moved into it. 

Finally, there is a yet more difficult case, when we have to bring 
up from the bottom of a mine a patient with a broken thigh or leg. 
In the majority of mines, there is no other way than to drag the 
sufferer along narrow galleries to the nearest shaft, and to raise him 
in the same bucket which serves for hoisting the mineral. M. Vallet 
has devised for this case a very simple and ingenious apparatus, 
Called the lit de mine. It is a sort of elongated chest, about sixteen 
inches wide, much like a coffin, but uncovered, and with a bot- 
tom somewhat concave; it is furnished with a thin mattress, having 
toward the centre a ridge about four inches high, so as to afford a sort 
of Beat when the patient is nearly in the vertical position; the sides 
are hinged to the bottom, thus allowing the patient to be placed in 
m with the least possible lifting, by turning them down; when 
: . they are held together by hooks. The head-board is likewise 
hinged ; the foot-board is composed of two separate and independent 
that o:e' only being fastened which corresponds to the sound 
so that this alone is made firm. The patient, laid on the bot- 
tom, is also held in place by girths fastened behind him, and crossing 
one another over the chest, pelvis and thighs. 



A TREATISE ON FRACTURES. 147 

This box is carried horizontally in the galleries of the mine, either 
by leathern handles, or by wooden ones which may be used at will as 
feet, in case of having to stop in muddy or wet places. Arrived at 
the shaft, the box is attached to the rope by means of four chains, 
two at its upper end and two about the middle. If the shaft is nar- 
row, the box should go up nearly vertically; if wide, its position 
should be made more or less horizontal by shortening the chains at- 
tached at its middle part. When brought out from the shaft, the 
box becomes a hand-barrow, in which the patient may be at once 
conveyed to the place where he is to remain during the treatment. 

The usefulness of this apparatus is not limited to mines only; and 
as the author points out, its construction fits it, in case of inundation 
or fire, for rescuing bedridden patients who are placed in danger.* 

§ II. — Of the proper position for the Limb. 

We shall not here discuss the position to be given to the limb in 
each particular fracture; this will be taken up at the proper time and 
place. But we must first of all inquire what should be the general 
attitude of the member; whether it should be flexed or extended. 

For the upper extremity, it is almost invariably the custom to 
keep the elbow at a right angle, the forearm being supported in a 
sling. Some exceed this degree of flexion, shortening the sling so 
that the wrist is above the level of the elbow. If, however, the 
patient keeps his bed, the limb, laid upon cushions, is less bent; but 
it is remarkable that it never has been proposed, except in frac- 
tures of the olecranon, to put the upper extremity in the extended 
posture. 

On the contrary, from the earliest times, extension has been pre- 
ferred for the lower extremities. To explain and justify this dif- 
ference, Hippocrates alleged the habits of the limbs, the upper re- 
maining flexed by preference, and the lower extended. Galen found 
a better reason ; he studied the mean figure of the limbs, that is to 
say, the posture which, avoiding the extremes, fatigued the muscles 
least, and could be longest maintained without pain; and he found 
this to be no other, even in the lower extremity, than a certain de- 
gree of flexion. But as this would have led to results too directly 
opposed to the practice of Hippocrates, Galen preferred a middle 
course; and adducing the law of habit, he alleged only that some 
persons who followed sedentary pursuits remained constantly seated 
and with their lower limbs flexed, and hence that in them, as an ex- 
ception, flexion was preferable. Moreover, in limiting the degree of 
his reform, he forgot what alone could give it some reality, viz., the 
means to be employed. He says indeed that he has seen his ideas 

* Gazette Medicate, 1835, p. 455. 



L48 A TREATISE ON FRACTURES. 

verified by ezperienoe; but be neither describes any new apparatus, 
nor any modification of the old. Later, Fabricius of Acquapen- 
dente extolled more highly than did Galen bimself the utility of the 
semiflexion of the limbs, though like Galen he shrank from putting 
his theory into practice; and it was not until the eighteenth century- 
thai it was made, by Pott, the general rule for the treatment of 
fractures of the lower extremities. 

Pott's doctrine is founded at once on theory and on practice. He 
commences by establishing that from the muscles arises the whole 
difficulty of reduction; the resistance depending on the position of 
the limb putting them in a state of tension. The natural conse- 
quence is that the limb should be so placed as to relax the muscles, 
making them offer the least possible resistance; this position being 
that of semiflexion. "Moreover," adds Pott, "all that I say is 
based on a long experience of my own, and on that of several other 
surgeons ; upon repeated trials in a great many cases, so successful 
that I do not fear to say that such as will follow our plan will be as 
successful as we have been." 

Pott's method was in fact soon and generally adopted throughout 
England; but in France, Desault had authority enough to cause its 
absolute rejection. This he based upon several reasons: the dif- 
ficulty of making the necessary extension on the broken bone; — the 
impossibility of accurately comparing the two limbs ; — the inconveni- 
ence of lying on the side, and the injurious pressure sustained in this 
position by the trochanter major; — the derangements to which the 
fracture is liable when the patient goes to stool; — the difficulty of 
firmly fixing the leg; — the impossibility of adopting this method 
when both limbs are broken; — and lastly, the results of experience. 
Of these reasons, the first two are really of singular insignificance; 
the others have reference only to the decubitus advised by Pott, and 
not to the method itself; and as to this great word experience, which 
would seem to decide the question, it will be enough to say that 
Desault had only tried semiflexion in two patients, one of whom, in 
Bpite of the most scrupulous attention, had a considerable degree 
of shortening. 

But Bichat added another and more specious objection, and one 
which had more influence. What we gain by relaxing some muscles, 
said lie, we lose by the tension of others; the knee cannot be flexed 
without stretching the quadriceps; the rectus femoris, relaxed by 
flexing the thigh, is made tense by flexing the leg; and lastly the 
superior and posterior muscles of the thigh, as the gluteus maximus, 
are also made tense. Dupuytren has triumphantly refuted this argu- 
ment of Bichat. It is true that if the limb be placed in extreme 
flexion, the extensor muscles may be rightly said to be so stretched 
as to destroy the good effect from the relaxation of the flexors; just 
as in the extended position, the relaxation of the extensors is more 



A TREATISE ON FRACTURES. 149 

than counterbalanced by the tension of the flexors. But in semi- 
flexion, or even in flexion at an angle of 135°, no muscles are 
stretched; all partake of the relaxation, which is the best condi- 
tion for reduction. 

Lastly, M. Bonnet has very recently resumed this discussion upon 
a new basis, opposing semiflexion from reason, experiment, and clini- 
cal results.* His argument does not, however, differ from that of 
Bichat, and hence need not be here repeated. What he calls clinical 
results are merely judgments, more or less unfavorable, passed upon 
semiflexion by Larrey, MM. Cloquet and Be'rard, Yidal and Gerdy ; 
authorities opposed to other authorities, serving at most only to keep 
the balance undecided. There remain the experiments, to be more 
seriously examined. 

M. Bonnet's experiments, although arranged by that author in 
five series, are all comprehended in this : in a dead body, the legs 
being stretched out, he made at the outer side of the thigh an inci- 
sion two or three inches long, and by means of this opening he sawed 
through the femur obliquely. At once there was an overlapping of 
nearly an inch, which, however, readily disappeared on slight trac- 
tion being made on the leg. If, then, the body was moved so that 
the knees projected over the edge of the table, and the leg was 
strongly flexed, the thigh still extended from the pelvis, extension 
was attempted in vain by the forearm placed in the ham ; in propor- 
tion as the leg was flexed there occurred a gradual shortening, which 
was at least one inch when flexion was carried to a right angle, and 
which no traction, however powerful, could overcome. The author 
has not confined himself to the mere result of his experiments ; he 
has sought for them an explanation which should enable him to apply 
them to the living subject : and this he has worded as follows : The 
displacement of the loiver fragment, induced in fractures of the femur 
by flexion of the knee, should be attributed to the new relations as- 
sumed by the articular surfaces, and to the pressure of the condyles 
of the tibia upon the condyles of the femur. 

What strikes one at once here is, that the semiflexion produced by 
M. Bonnet in the dead subject is a position which cannot be given 
to living patients, and entirely different from surgical semiflexion. 
But, not to dwell on this objection, I repeated his experiments, and 
obtained the following results. 

If the femur of a body in a state of cadaveric rigidity be sawed 
through, the effect will be nearly that indicated by M. Bonnet. A 
simple reflection will show that it cannot be otherwise. The muscles 
of the thigh, stiffened in the extended position, are like cords nearly 
incapable of being stretched ; it is well known how much force must 
be used to bend the knee under such circumstances ; M. Bonnet him- 
self has admitted that the tension of the quadriceps is so consider- 

* Bonnet, M^moire sur lesfract. du femur, etc. ; Gaz. Midicale, Aug., 1839. 



150 A TREATISE ON FRACTURES. 

able thai the knee cannot be flexed without rupturing a good many 
of its fibres. The Femur being sawed through, the muscle resists 
flexion quite as strongly; it is the bone which yields, by overlapping. 
Extend the limb again; the quadriceps, no longer stretched, offers 
no resistance; the flexors, stiffened in a state of elongation, and not 
in any way rendered tense, are equally passive. Reduction is then 
easy in the extended position, because the muscles have become stif- 
fened in this position, and not because of the position itself. 

But if this be so, then by dividing the femur in a body stiffened in 
a state of semiflexion, we ought to get directly opposite results. I 
have made this counter-experiment; and then, as might be foreseen, 
reduction was easiest during flexion ; but in extension the stiffness of 
the flexors rendered it impossible. Lastly, I have repeated these 
experiments in subjects without cadaveric rigidity, all the muscles 
being loose and flaccid ; and then there was in no position of the 
limb either overlapping or resistance, except, indeed, from the weight 
of one or the other fragment. 

Hence we see what is to be thought of M. Bonnet's experiments, 
and of the pretended pressure exerted during flexion by the condyles 
of the tibia upon the femur. The condyles of the tibia cannot act 
of themselves, except by their weight ; to exert any pressure what- 
ever, they must first themselves sustain it; and according to the 
direction of the pressure they sustain, do they sometimes press more 
during flexion, and sometimes during extension. 

In fine, the only active resistance to be overcome in the reduction 
of fractures belongs entirely to the muscles; and this simple fact 
suffices to show beforehand the nullity of experiments made on the 
dead body. Muscular action cannot be studied except where it ex- 
ists ; hence experiments must be made of necessity upon the living 
subject. I have therefore proceeded as follows.* 

In a rabbit, I passed an iron pin into the substance of the tro- 
chanter, and another into the external condyle, so as to have in their 
projecting heads two fixed and invariable points for measurement; 
after which I broke the thigh, and made the fragments overlap. 
Then proceeding to the reduction, I put a counter-extending noose 
under the perineum, within the tuber ischii, fixing it above to a firm 
hook ; the extending loop surrounded the thigh immediately above 
the knee, and was stretched by weights. I could thus measure the 
elongation of the limb, under the traction of the same weight, in dif- 
ferent positions; the results were as follows: 

Complete Extension. Moderate Flexion. 

Traction with 2500 grammes, 75 millimetres. 80 millimetres. 

" 1750 " 70 " 75 

Complete Extension. Moderate Flexion. 

[Traction with about 6§ pounds Troy, 2| inches. 2| inches. 

" 4f " " 2£ " 2£ inches.] 

Ezarrik n des doctrines chir. relatives d la reduction des fractures ; Journal 
de Chirurgie, 1845. 



A TREATISE ON FRACTURES. 151 

In another rabbit, placed under precisely similar conditions, only 
with the extending loop placed on the leg above the malleoli, and 
the flexion of the knee effected by means of a double inclined plane, 
the results were the same : 

Complete Extension. Moderate Flexion. 

Traction with 2000 grammes, 60 millmetres. 65 millimetres. 

" 1500 " 57 " 62 " 

" 1000 " 55 " 60 

Complete Extension. Moderate Flexion. 

[Traction with about 5| pounds Troy, 2 inches. 2£ inches. 

" 2£ " " 1^ " 2 T V inches. 

" 2f ♦ " « 1£ « 2 inches.] 

In a third rabbit, I performed the same experiment on a broken leg. 
A weight of 500 grammes [about one and two-fifths pounds Troy] 
brought the limb down eight centimetres [two and two-thirds inches] 
during extension, and eight and one-quarter centimetres during 
flexion. 

We see, then, that when muscular action is still within physiolo- 
gical bounds, in all recent fractures, moderate flexion is constantly 
found more advantageous than extension ; and that, with an equal 
power, it allows greater stretching of the muscles ; the difference 
being slight in the leg, but amounting in the thigh to one-eleventh or 
one-fifteenth. When the muscular contraction assumes by its degree 
a pathological character, the results vary somewhat, according to 
the degree of inflammation, and there is even a point at which the 
influence of position seems superseded by the violence of the con- 
traction. 

Thus in the second of my rabbits, the fracture of the thigh being 
of forty-eight hours' standing, and the muscles giving way a little, 
under a force of three kilogrammes, [between seven and eight pounds 
Troy,] the limb when extended was sixty millimetres in length, 
when slightly flexed, sixty-five. 

In the first, the inflammation being more active, it required more 
than six kilogrammes to elongate the extended limb to seventy 
millimetres ; even in semiflexion it hardly reached quite seventy- 
three. 

Lastly, in the one in which I broke the leg, the inflammation en- 
tirely did away with the slight advantage which in the physiological 
condition would have resulted from the semiflexed position. 

But apart from these experiments, which would seem to me defi- 
nitely to settle the question, are there not sufficient reasons against 
the extended position in the treatment of fractures ? It is certain 
that complete extension, like complete flexion, is a fatiguing and 
painful position when kept up long. If we would seek reasons for 



152 A TREATISE OX FRACTURES. 

this incontestable fact, anatomy shows us that the ligaments are 
Stretched, and the articular cartilages pressed against one another. 
Physiology in its turn shows that certain muscles are put into a state 
of forcea tension; and experiments, in which by section of the 
nerves the muscles were deprived of all but their vital contractility, 
have BhoWD me that muscular action opposes as well complete exten- 
sion as complete flexion, ceasing to act only when the limb is removed 
from either extreme.* Lastly, clinical experience would furnish, in 
favor of the intermediate posture, at least two irrefragable arguments, 
which would only coufirm our anatomical and physiological data : the 
first, upon which I have already dwelt sufficiently, (see p. 118,) is that 
extension renders the patient more liable to stiffening and to anchy- 
the second is, that semiflexion facilitates difficult reductions. 
On this point, opponents as well as adherents bear the same testi- 
mony. "Sometimes," says Boyer, " the difficulty of the reduction 
arises from the forced extension of the limb and the unequal stretch- 
ing of the muscles ; it may be obviated by putting tbe limb in a state 
of semiflexion." 

Whence, then, comes the difference of opinion in tbis respect, and 
the reproach cast upon semiflexion? Several reasons may be given. 
In the first place, more is expected of the position than it can ac- 
complish ; and it should be observed that its advocates themselves, 
by exaggerating its advantages, have justified these criticisms. That 
it facilitates reduction appears to me beyond any sort of doubt ; 
but it is rarely sufficient to produce it, or to maintain it when pro- 
duced. 

In the second place, it is not sufficiently determined to what degree 
of flexion the limb should be brought. Pott defined almost mathe- 
matically the half-way position ; and in the figures illustrating his 
process, we see the leg flexed on the thigh at an angle of 112°. The 
double inclined plane of Sir C. Bell presents an angle of 115° 
to 125°. Sir A. Cooper widened his to 135°; but it is rarely that 
I flex the knee to more than 150°, and frequently I make the angle 
much greater, especially in fractures of the leg. In my experiments 
on animals, I have generally found extreme flexion less favorable 
than extreme extension, and flexion to one-fourth better than semi- 
i. properly so called. Experience has also taught me that the 
degree of flexion should not be the same in all subjects, or in all sorts 
of fractures ; and, particularly in cases with active inflammation, it 
lispensable to deviate from the usual rule.f 

Chirurqicale, tome i. p. 108. 

f Tl have proved that the extent of motion of the knee 

from ' osion to extreme flexion, measured in but two subjects, dif- 

y nearly 17-. < Vrtainly the differences found in measuring a larger num- 

;id be much greater. (See Traitt mtcanique des organes de 

la locomotion, in V Encyclopedic Anatomique, tome ii, p. 344. 



A TREATISE ON FRACTURES. 153 

Lastly, there is often a mischievous confusion made between the 
method itself and the means of applying it. Thus the posture on 
the side, advocated by Pott, but so vehemently opposed by Desault, 
has long fallen into disuse except in purely exceptional cases. I have 
seen employed at the Hotel-Dieu, within twenty years, inclined planes 
of wood, or even of iron, whose angle, nearly 90°, excoriated the 
ham. Dupuytren erred in a different way, making inclined planes 
by means of pillows, which sunk in from the weight of the knee ; 
such modes of applying the method are evidently improper. 

It is not enough to prescribe a position for a broken limb ; it must 
be maintained fixed and immovable till consolidation is complete, 
and be guarded against all sources of displacement. Among these 
are prominent, (1) a want of solidity in the plane sustaining the 
limb ; (2) partial pressure, causing intolerable pain ; (3) the weight 
of the covering, of the limb, or of the trunk ; (4) the movements of 
the patient. 

In fractures of the upper extremity, the patient can generally sit 
up ; semiflexion is maintained by supporting the arm in a sling, or 
in a hollow splint, fixing the whole to the side by a bandage, if neces- 
sary. When the patient is obliged to keep his bed, the limb is placed 
on cushions stuffed with oat-straw ; but these cushions soon sink in, 
causing serious inconvenience. To put a board under the cushions 
is neither easy nor certain, on account of the elevation at which the 
limb is to be kept ; the suspending apparatus of M. Mayor, although 
doubtless useful, involves much trouble; the best plan, therefore, is 
to watch the cushions, and correct their displacement whenever it 
occurs. 

Fractures of the lower extremity, which nearly always impera- 
tively require that the patient should keep his bed, demand also more 
care, especially on account of the weight of the limb. J. L. Petit 
was perhaps the first to recommend the use of mattresses without any 
feather bed, and to put between the two mattresses a board long 
enough to reach from the foot up to the hip. Duverney pointed out 
another method more nearly approaching to the modern hyponarthe- 
cia. It requires a board long enough to reach from the foot to the 
buttock, and two or three inches wider than the limb itself; this is 
covered by a firm hair mattress of the same length and breadth, and 
both are covered and held together by a sheet well stretched and 
sewed over them. On this board rests the injured limb, the sound 
one being placed on two pillows, one for the buttock and one for the 
leg and thigh ; lastly, a compress of sufficient thickness is put under 
the ham, to prevent its being displaced. These two methods are 
essentially adapted to the extended position of the limb ; the choice 
between them is matter of indifference, the main point being the 
fulfilling of the existing indications. When semiflexion is resorted to, 
it is much more important still to have a solid plane the whole length 



L64 A TREATISE ON FRACTURES. 

of the limb, and the employment of a wooden or metallic inclined 
plane becomes indispensable. 

But in looking to the solidity of the sustaining apparatus, we must 
guard against such firmness as to give rise after a time to painful 
pressure. Long-continued lying on the back is usually said to give 
• sloughing over the sacrum, in patients of advanced years. 
With a view of obviating this danger, J. L. Petit proposed to make 
a hole in the mattress at the part corresponding to the sacrum; and 
more recently there has been contrived an apparatus, in fact several 
have been invented, so that the patient may be raised, and the but- 
tocks exposed to the air, without disturbing the extremities. Dau- 
jon's bed, employed in the Parisian hospitals, will give an idea of all 
the rest. It consists of a movable wooden frame, having stretched 
on it a ticking pierced at about the centre with a hole five or six 
inches in diameter; a mattress and sheet, with corresponding open- 
ings, arc placed upon this ticking; the patient is placed on this mat- 
tic—, and by means of four cords, one attached to each corner of 
the frame, passing over pullies at the tops of the bed-posts, and 
meeting on a windlass, it will be seen that the frame, mattress and 
patient may all be raised together by turning the crank; and thus 
the sacrum, situated opposite to the central orifice, may be at will 
relieved of all pressure. These arrangements are useful also in an- 
other respect, which is in allowing the patient to go to stool without 
at all disturbing either the trunk or the limbs; and it may be well 
to remember that the perforation of the mattress for this purpose 
dates back to the times of Paulus iEgineta. But while their conve- 
nience is recognised, their importance should not be exaggerated ; 
most commonly there is no difficulty about the evacuations, and as 
to sloughing over the sacrum, provided that the patient rests on a 
properly stuffed mattress, old persons are no more liable to it than 
others; I .-hall elsewhere recur to this point in speaking of accidental 
symptoms. 

T essure on the heel rarely causes sloughing; much oftener it 
causes severe and incessant pains. A. Pare, who had experienced 
them, relates that, to obtain relief, he had the heel raised up from 
time to time; again, he had a down-cushion placed under it, as well 
as under the buttocks; afterwards he had a sort of hollow tin splint 
made, so notched under the heel as to make no pressure upon it; 
and to protect it still more, he kept the splint off the skin by a 
thick compress slipped under it. Duverney proposed to put under 
tnr heel apiece of sponge, which would be at once supple, resisting, 
and elastic. Some surgeons of his time used faux-fanons> or a 
roller with two heads, between which the heel was lodged; only it 
was recommended to have the bandage so wide that the roll on 
each side should reach up as far as the commencement of the calf of 
j. For my own part, I satisfy myself with placing between 



A TREATISE ON FRACTURES. 155 

the heel and calf compresses of wadding, so that the leg may have 
equal support at all points of its posterior surface, the heel only 
being left free. 

These precautions should be observed as well when the limb is ex- 
tended as when it is semiflexed ; but when the latter position is pre- 
ferred, and a double inclined plane is used, other parts may likewise 
suffer from undue pressure. The ham suffers when the angle is too 
sharp, or insufficiently covered; but by reason of the wide angle I em- 
ploy, I have not had a single patient to suffer from this. The tuber 
ischii sometimes gives more trouble. The head and shoulders being 
raised by the pillows, the trunk tends to slip clown toward the bottom 
of the bed ; and the tuber ischii comes to press either on the surface 
or on the upper edge of the femoral part of the splint. If the fracture 
is in the leg, this portion can be easily shortened ; but in fractures 
of the femur, where the full length of it is needed, we must carefully 
pad it so as to lessen the pressure, and if necessary, keep the trunk 
up by means of a loop passed under the perineum and attached to 
the head of the bed. 

The weight of the coverings may do harm in two ways : sometimes 
by pressing at the seat of fracture, sometimes by acting on other 
points of the limb, so as to twist it. It has therefore become cus- 
tomary to sustain them by hoops placed opposite all the points needing 
protection. In simple fractures of the lower extremity, I usually 
protect the point of the foot by means of the high foot-piece of the 
double inclined plane. 

It is in fact upon the toes that pressure is at once the most painful 
and the most injurious, because it favors the natural tendency of the 
foot to fall outward. Even without pressure, if left to itself, its own 
weight will often throw the foot over in this direction; and it is im- 
portant to hold it up either by means of a cushion, a foot-board, or 
two lateral splints. 

Another much more serious danger, and particularly because it 
has attracted less attention, arises from the weight of the trunk 
itself. It has already been said that by reason of the elevation of 
the head and shoulders, the body tends to slip down in the bed ; and 
besides the inconvenience so caused, by pressure on the tuber ischii, 
the trunk cannot slip down without pushing on the upper fragment, 
tilting it up, and making it overlap the lower. This is the reason 
why even when permanent extension is not called for, we must always 
keep the body up by means of a perineal loop; and this necessity 
will be still more clearly shown in treating of the movements which 
the patient may be allowed. 

This is not all; while the fractured limb and the corresponding 
half of the pelvis are supported by the apparatus, the other half of the 
pelvis and the other limb lie unconfined on the mattress, making in it a 
hollow which daily becomes more marked, so that the whole body at 



156 A TREATISE ON FRACTURES. 

last inclines toward tlie sound side, drawing along with it the upper 
fragment^ which thus inevitably forms an angle with the lower. In 
very fleshy subjects, the danger is augmented by their weight, but it 
is also more easily counteracted; for we need only have the board be- 
tweeD the mattresses, as proposed by J. L. Petit, lengthened so as to 
reach a little beyond the buttocks, and widened so as to equal the 
bed, in order to give an equable support to the pelvis and limbs. If 
en the contrary the patient is spare, giving reason to fear the effect 
of pressure upon the sacrum by the board, we must be satisfied with 
supporting the sound side by means of cushions, after Duverney's 
method ; but with the indispensable precaution of daily watching and 
arranging them. 

[It may be doubted whether the mere weight of the patient does 
not tell equally upon the skin where there is a thick layer of fat 
above it, and where there is but little; and perhaps the advantage of 
that layer, however great, may be counterbalanced by the additional 
weight which its presence involves.] 

It would now remain for us to inquire how the different movements 
of the patient derange the position of the limb, and how to obviate 
such movements; but this subject belongs to a most important ques- 
tion, to wit, what motion may the patient be allowed, if any ? which 
will be discussed in a separate section. 

Now, the limb being placed in a suitable posture, and all the pre- 
cautions necessary to maintain this being taken, we must, unless for 
some special reason, proceed to the reduction. 

§ III. — Of the Reduction. 

The operation of reduction has for its object the correction of the 
displacement of the fragments, and the giving to the bone its natural 
direction, form and length. 

From this simple definition, we may judge of the folly of some 
surgeons in attempting to reduce fractures in which there is no ap- 
preciable displacement. There are two very distinct cases in which 
all attempts of this kind are absurd; first, when it is ascertained 
that there is no displacement; secondly, when one cannot establish 
the fact of its existence, on account of the depth of the fracture or 
the swelling of the soft parts. I might add still a third case, when 
although the displacement is completely made out, we have no means 
of reducing it. 

It is evident, moreover, that the process of reduction varies with 
the displacement itself. When there is merely an angular deviation, 
it suffices to bring the lower fragment into a suitable direction, and 
the reduction is effected. It is so also in some cases of displacement 
by rotation, when the fractured surfaces are smooth, and glide readily 
upon one another. Transverse displacement, on the contrary, ge- 



A TREATISE ON FRACTURES. 157 

nerally obliges us to resort to coaptation; this is a process in which 
we sometimes press with the thumbs on the projecting fragment, so 
as to push it back to the level of the other, and sometimes, grasping 
one fragment with each hand, we push them back simultaneously. 
These means fail when in a serrated fracture the ends are so inter- 
locked that they must be separated in order to overcome their im- 
paction ; each fragment must then be drawn in a different direction. 
These tractions receive the general name of extension; the term 
is however usually limited to the force exerted on the lower frag- 
ment, that on the superior being called counter-extension. 'They 
are much more necessary when there is impaction or overlapping; 
when on the contrary the fragments tend to separate, as in fractures 
of the patella, the limb must be first placed in the position bringing 
them closest together; after which the reduction consists merely in 
pushing them toward one another. 

The majority of these processes offer little difficulty, and need no 
further description. But the extension of the limb is a far more 
delicate matter, and suggests various questions. 

The first question which occurs is as to the agents to be used in 
making traction; in this respect there may be counted three very 
different lines of practice. According to Desault, Boyer, and nearly 
all the modern school, the hands of assistants always suffice. Celsus, 
Paulus 2E gin eta, the Arabians and their disciples, and more recently 
Duverney and most of the Academie Roy ale de Ckirurgie, resort to 
loops in difficult cases. Lastly, Hippocrates in ancient times; A. 
Pare, Fabricius of Acquapendente, Fabricius Hildanus, Wiseman 
and J. L. Petit, in modern times ; and Monteggia, at a date still 
nearer to our own, recommend the use successively of the hands, of 
loops and of machinery, as we may find them necessary. "If the 
extension made by the hands of the assistants is sufficient," says 
Hippocrates, "we should make use of it alone; for it is absurd to 
apply apparatus where it is not needed. But if the strength of as- 
sistants does not suffice, we must resort to more powerful means, and 
then the most convenient should be selected." 

Nothing more proper could have been said, in our opinion. There 
are cases where the surgeon does not even need any assistants, he 
himself easily making extension and counter-extension; such are 
fractures of the phalanges, and even those of long bomes in very 
young subjects. At other times the strongest muscles may be over- 
come by two assistants pulling in contrary directions, provided the 
limb affords sufficient hold. But when this hold is wanting; or when 
the muscles, from their number or from being irritated, are power- 
fully contracting, we cannot understand how the doctrine of Desault 
and of Boyer could obtain so general an assent, in spite of the con- 
trary practice of all ages, and in spite of the facts daily opposing it. 
There is perhaps not a single fracture of the femur which could be 



158 A TREATISE ON FRACTURES. 

reduced merely by the hands of assistants, except it might be in 
children or in some debilitated subjects. I speak of quite recent 
fractures; when inflammation is set up, as just now said, even our 
apparatus will not suffice. This is still further the case when the 
fracture is of a month's standing or more; and Boyer reports two 
instances of fracture of the femur, one dating back forty days and 
the other four months, in which, notwithstanding the steady use of 
mechanical means, he could not bring the limb down to its natural 
length. I am well aware that many surgeons think themselves to 
have obtained reduction of fractured thighs by the hands of assistants, 
and as a result, consolidation without shortening; for myself, except 
in children, I have never seen a single one; and I would add that 
all the successful results thus stated are wanting in the only admis- 
sible proof, the exact measurement of the limb. 

It needs only that one should try, or see tried, a reduction of this 
kind, to prove convincingly that counter-extension by an assistant 
holding the pelvis is entirely illusory. The assistant is hampered, 
he has no purchase, and can only exert a force equal to about thirty 
kilogrammes, [not quite seventy pounds avoirdupois.] Now to this 
force are opposed sometimes the forces of two other assistants pulling 
on the leg or knee ; how much can the former resist ? 

The first rule for making counter-extension, which has been too 
much forgotton, is to employ such a retaining force that the tractile 
efforts, powerful as they may be, cannot overcome it, and will hence 
be expended in stretching the muscles. Thus for all fractures of the 
femur, for some fractures of the leg; in a word, for every fracture 
which calls for the employment of great force, I would have counter- 
extension made by means of loops attached to a fixed point, such as 
a ring built into the wall, as in luxations, or to the head of the bed. 
In this way only can we be sure of wasting none of the extending 
power, which may be made according to the necessity of the case, by 
assistants, by loops, or by machinery. 

As to the question of the choice between these means, it may be 
solved in a general way, from scientific data; and in each particular 
case, by the measurement of the limb, revealing to the surgeon the 
effect produced. 

I have demonstrated by direct experiment, that a robust man, 
pulling steadily and without jerks, and without any purchase for the 
body or feet, does not exert more than a force about equal to forty 
kilogrammes, [about ninety pounds avoirdupois;] and few assistants 
will reach this amount.* If we employ two or more, they want pur- 
chase on the limb, and hinder each other; so that much power is 
lost. Therefore, when one assistant is not enough, I make it a 
general rule to employ several loops surrounding the limb, in order 

* See my Anatomie jClurugicale, tome i, p. 115. 



A TREATISE ON FRACTURES. 159 

that all the assistants may pull without being in one another's way ; 
thus one can estimate approximative^ the amount of force applied, 
and graduate it by increasing or lessening the number of assistants. 
Generally, in pulling on the lower extremity, the force may be much 
increased by setting the feet against the patient's bed; I have by 
experiment found it nearly doubled in this way. 

It will be seen from this what power may be brought to bear with 
two or three assistants provided with loops; and in the majority of 
cases we may dispense with machinery. But it must be considered 
that the force exerted by assistants is very variable, and hard to 
regulate ; a man may make a steady pull equal to thirty kilogrammes 
without setting his feet, or with such an advantage, may reach fifty 
kilogrammes ; and this same man, by a sudden jerk, may go as high 
as ninety kilogrammes. There is therefore one precaution very 
necessary in employing assistants ; they must be directed to act 
slowly, by steady traction; without any jerking, so as to avoid a 
sudden and violent pull, endangering the rupture of nerves, muscles 
and vessels. 

Machines on the contrary are manageable, acting only gradually, 
and to a certain degree ; they are not so capricious as human mus- 
cles, nor so rude as assistants; they are superior in every respect 
except in the difficulty of having them at hand; often also their 
complexity is an objection to them. The mechanical splint of Boyer 
is an excellent apparatus for producing extension in fractures of the 
lower extremity ; but from its limited application it has nearly fallen 
into disuse. The glove of A. Pare, in favor with Fabricius Hildanus 
and with Ravaton, available both for fractures and luxations, has the 
disadvantage of needing a fixed point more difficult to find than that 
for counter-extension. The difficulty is the same in luxations as in 
fractures ; and in both cases, I hold to the rule given by Hippocrates, 
that recourse should not be had to machinery, nor even to loops, 
unless in case of necessity; but that in all cases the power used 
should be in proportion to the resistance. 

Another discussion has been started as to the point of application 
either of the loops or of the assistants' hands. Hippocrates attaches 
little importance to this ; thus in fractures of the thigh, he would make 
counter-extension sometimes from the perineum, sometimes from the 
axillas ; and the extension at once from above the malleoli and above 
the knee, in order to avoid too strong traction on the latter articula- 
tion. J. L. Petit was the first to direct the force to be exerted only 
on the broken bone, with the double aim of losing no power and of 
protecting the neighboring joints. Dupouy and Fabre would give us 
exactly opposite advice; saying that the tractile force should never be 
applied on the broken bone itself, but on the bones situated immediately 
above and below it. Dupouy argues that we thus gain power, and 
Fabre adds that by acting on the injured bone, we compress, stretch 



160 A TREATISE ON FRACTURES. 

and irritate the muscles surrounding it, making them obstinately 
£ tension.* Lastly, Desault goes still further, recommending 
the removal of the extension and counter-extension as far as possible 
from the Beat of fracture ; in fractures of the thigh, for instance, he 
would draw on the foot and not on the leg, for the reason, says he, 
that the power of the extending force is generally in inverse ratio to 
• .in v from the opposition to be overcome. This is a mistake in 
mechanics, long since pointed out; and Desault's practice in this 
respect lias justly fallen completely into disuse. 

1 1 is otherwise with the doctrines of J. L. Petit and of Fabre ; 
the former has its supporters chiefly in England, and the latter, em- 
braced by Boyer, has become a sort of law in France. For my 
own part I adhere exclusively to neither, rather imitating the prac- 
tice of Hippocrates. In fact, unless a very great force is to be 
applied, it makes little difference whether we put it on the lower 
fragment, or on the neighboring bone; the only determining motive 
is the greater facility of grasping the limb at either point. Thus in 
a recent fracture of the thigh, I prefer acting on the lower part of 
the leg, where the loops can be better attached ; I have never known 
patients so treated to complain of pain in the knee ; and the increase 
of power alleged by Dupouy seems to me to be only in the better 
purchase afforded. In the humerus, on the contrary, I prefer seizing 
the arm above the condyles, where I find the double advantage of a 
better hold and more direct traction. But when very great resist- 
ance is met with, I have several times known patients to complain 
of pain in the joints so stretched, even for a long time afterwards ; 
the reduction of old luxations has afforded the most striking examples 
of this. Hence it is then preferable to follow the practice of J. L. 
Petit, or even- to employ two loops for extension, in imitation of 
Hippocrates. 

Whatever means are employed, extension must be begun in the 
direction of the lower fragment, to bring it down into the natural 
line of the limb; we must proceed slowly and without jerks, to avoid 
all risk of irritating or rupturing the muscles ; and we must gradu- 
ally increase the power till it is judged to be sufficient. It is very 
important that, during this time, the patient should make no move- 
ment of either of the other limbs, or even of the head ; the injured 
limb shares more or less in any such motion, and the muscles are 
consequently thrown into action. I submitted to continuous exten- 
sion, for twenty-four hours, a recent fracture of the femur; at the 
end of this time I removed the extending loops, to examine the state 
of the skin : the limb shortened hardly three or four millimetres. 
The patient tried to raise his head to see what was going on, and 

* Dupouy, Reflexions, etc.; Journal de Mtdecine, 1767, tome xxvi, p. 170; 
Fabre, Eseats sur Difftrents Points de Physiologie, etc., Paris, 1770, 8vo, 
p. 242. 



A TREATISE ON FRACTURES. 161 

the shortening increased immediately to a centimetre; here the lower 
fragment was drawn up, the pelvis being still held in place by the 
loops attached at the head of the bed. Lastly, in some cases we 
may profit by Dupuytren's advice, and divert the patient's attention 
by conversation or by other means. 

But while the extension is being made, what is there for the 
surgeon to do ? He has two important duties to perform: to see that 
the extension is sufficient, and then to proceed to coaptation. 

In fractures just beneath the skin, such as those of the tibia or of 
the clavicle, one can often follow with the eye the change of place 
of the fragments, and when they are seen to be in apposition, this 
constitutes the best proof of sufficient extension being made. But 
when the swelling obscures the bone, when powerful traction stretches 
the superjacent skin, and in all fractures buried within a mass of 
muscles, neither sight nor touch reveal anything regarding the amount 
of extension, either which is requisite, or which has been already 
effected. 

If fractures always presented regular surfaces, it would be enough 
to give the limb its normal length, to allow the fragments to go into 
place; but as in the majority of cases they are irregularly serrated, 
we see the propriety of the rule given by Hippocrates, to carry the 
extension a little further. But, admitting this rule, the difficulty is 
to judge in each patient whether or not the requisite degree has been 
attained; Hippocrates is silent on this point, and none of his suc- 
cessors seem to have been aware of the omission. They all direct us 
to produce coaptation at all events, not considering that it may be 
impossible; for, I repeat, it is this possibility, or in other words the 
availability of extension, which must first be ascertained; and the 
only means of doing this is by a new measurement. 

It is necessary therefore that while the assistants are pulling, the 
surgeon, duly acquainted with the shortening caused by the fracture, 
should measure the elongation which they produce, making them 
keep it up until the desired point is attained. We have given 
general rules for measurement while on the subject of diagnosis, and 
need not here repeat them. When at last all is made ready for 
coaptation, it is proceeded with as already directed. 

Three difficulties may here occur to the practitioner. In the 
first place, he will not always find precisely the fixed points for mea- 
surement; he should then do his best toward supplying them, by 
bringing the two limbs together so as to compare them with his eye, 
aiding this by approximative measurement ; in a word, by leaving to 
guess-work as little as he possibly can. 

Secondly, after having to all appearance effected a complete reduc- 
tion, we often find the shortening to recur at once when the exten- 
sion is relaxed, so that nothing is really gained. This arises from 
the obliquity of the fracture, the surfaces being in no way prevented 



1G2 A TREATISE ON FRACTURES. 

from Bliding upon one another; or we may have to deal with a mul- 
tiple fracture, the splinters or intermediate pieces not affording due 
support to the ends of the main fragments. The only resource is 
then permanent extension, and all attempts at reduction should be 
Bnspended till this can he conveniently applied. 

Thirdly, even after having proceeded as regularly as possible, it may 
happen that coaptation cannot be attained, some unexpected obstacle 
preventing the fragments from approaching one another. For this 
there are three principal causes: sometimes the edges or the surfaces 
of the fragments do not correspond ; sometimes a splinter is caught 
crosswise ; or lastly, there may be interposed some of the soft parts. 
It is not always easy, often it is impossible, to know which of these 
conditions we have to contend with. When we suspect the first, we may 
begin by using more powerful traction, so as to separate still further 
the fragments in the line of their length, and thus to allow the pro- 
jecting portions to slip over one another. If this fails, we should move 
the broken ends in different directions, so as to bring different parts 
in contact, until the salient angles find the entering angles which 
correspond to them. Sometimes it is even necessary to make such 
a movement of circumduction that one fragment passes completely 
behind the other. I have seen a case of double fracture of the jaw in 
which reduction was impossible during life, and could only be produced 
in this way after death. M. Lisfranc has lately used it during life 
with complete success. The case was one of fracture of the leg 
downward and forward, the upper fragment of the tibia having 
pierced the integuments and passed back of the lower. The usual 
attempts at reduction having failed, the surgeon grasped the superior 
fragment, carried it by a semicircular movement before the other, 
and thus succeeded in reducing it.* 

In the second case, when a splinter gets between the broken ends 
and prevents reduction, we may, if the splinter is superficial, cut 
down upon it and extract it, according to the bold advice of Lan- 
franc. But the prudent surgeon should compare the dangers of the 
presence of the splinter with those of the incision, and only decide 
after mature consideration of all the circumstances. 

When, lastly, there is reason to believe that the fragments are kept 
apart by portions of the soft tissues, and every attempt at reduction 
has failed, the section of the intervening structures has been pro- 
posed by Laugier, who adopted it in the following case. A man, 
aged o5, had sustained a very oblique fracture of the right thigh; 
the upper fragment, which was very sharp, had pierced the muscles 
and aponeurosis, and even made a small wound of the skin ; but the 
first attempts at reduction had disengaged it from the skin, which 
was nearly healed. The end of the fragment, however, rested be- 

* Gazette des Hopitaux, Aug. 3, 1844. 



A TREATISE ON FRACTURES. 163 

neath the skin ; and any attempt at reduction only pushed it against 
the aponeurosis. M. Laugier introduced the tenotome at two different 
times ; but in spite of the division of the tissues, reduction was im- 
possible ; an abscess formed at the seat of fracture, and the patient 
died of purulent absorption.* This result is not, to be sure, very 
encouraging, and perhaps a direct incision through the skin would 
answer the purpose more readily. The practitioner must, however, 
make his choice ; to abstain from operating in such a case would cut 
off nearly all chance of consolidation, and condemn the patient to 
one of the worst of infirmities. 

This attempt of M. Laugier leads us to speak of an operation of 
the same kind, intended to accomplish reduction in spite of mus- 
cular contraction, viz., cutting the muscles across; a plan advocated 
by Celsus, but only in cases of compound fracture. In 1840, M. P. 
Meynier, and subsequently M. Laugier, divided the tendo Achillis 
subcutaneously, in fractures of the leg. M. A. Berard has thrice 
done the same operation in fractures of the external malleolus ; and 
on another occasion he cut not only the tendo Achillis, but also the 
tendons of the peronei. M. Meynier has not reported the result of 
his case ; of the five others, three are dead, and it is not known of 
the two cured whether they walk as easily and firmly as before.f 
We must therefore consider this as a last resort, which should be 
used with great caution, and only after the failure of all other means. 

§ IV. — Of the proper Time for attempting Reduction, 

This question has presented itself ever since the earliest times, 
and has been variously solved by practitioners. Thus, among the 
cotemporaries of Hippocrates, some waited until the third or fourth 
day, others until the seventh. Hippocrates opposed both these plans. 
According to him, extension should be attempted on the first or se- 
cond day; but on the third inflammation begins to develope itself, 
and our first object should be its abatement. This usually occurs 
toward the seventh day, sometimes later ; in all cases, we should 
wait till there is no more inflammation or fever, before resuming our 
attempts at reduction. 

This doctrine, reproduced by Celsus and by Galen, was sustained 
by Albucasis among the Arabians, and by Lanfranc among their 
European followers. It resumed all its vigor in the renaissance of 
Hippocratism, from the sixteenth to the eighteenth century ; and 
Bromfield even adds to the strictness of its precepts. Nearly all 
fractures, says he, are accompanied by contusion, and therefore by 
swelling ; hence the first indication is to dissipate this swelling, either 

* Laugier, Bulletin Chirurg., tome ii, p. 253. 

f See the Gazette Mtdicale, 1840, p. 552 ; Bulletin Chir. of M. Laugier, loc. 
cit.; and my Journal de Chirurgie, tome i, p. 441. 



1(U A TREATISE ON FRACTURES. 

by general or by local means. For this, eight or ten days may suffice; 
but it' a Longer time is required, reduction should not be attempted 
till after the entire disappearance of the swelling; and "though I 
have sometimes been obliged," says he, "to defer it for more than 
three weeks, the callus has presented no obstacle, and the consolida- 
tion has afterwards proceeded as perfectly as possible." 

Lastly, in our own day, two different lines of practice have been ex- 
tolled. On the one hand, Boyer and Larrey, advocates in general 
of immediate reduction, agree still in admitting two great contra- 
indications, viz., when the irritated muscles are affected with spas- 
modic contractions ; and when swelling, tension and pain denote a 
considerable degree of inflammation. On the other hand, according 
to M. Velpeau, neither inflammation nor spasm should induce any 
delay ; so far from that, immediate reduction is the quickest and 
surest method of alleviating them. 

The first question suggested by a statement so absolute is this : Is 
reduction always possible? In 1839, a coachman aged 30 sustained, 
while drunk, an oblique fracture of the leg. I saw him twelve hours 
afterwards ; the fragments of the tibia overlapped one another, and 
all the muscles of the leg were in a state of such violent contraction 
as to place reduction out of the question. Two bleedings, a rigid 
diet, and the administration of forty centigrammes [about four grains] 
of opium per diem, altered the state of things so that on the fourth 
day the contractions had ceased, and the coaptation was easily 
accomplished. 

This was a striking example of muscular spasm, which is rarely 
seen so strongly developed. Inflammation is far more common ; and 
I do not hesitate to say that, however slight it may be, it renders 
reduction of a fracture of the arm or forearm impossible by the 
hands of assistants alone. In a case of overlapping fracture of the 
forearm, with active inflammation, I treated the latter by topical re- 
medies, rest and compression, for five days; after which, the swell- 
ing having almost entirely gone down, I attempted reduction. I em- 
ployed assistants, two on each side, but all my efforts were fruitless. 
Quite recently, at the second day of a fracture of the thigh, I found 
three aids, with loops, unable to bring the limb to its normal length. 
And it was only because reduction was impossible, that MM. Mey- 
nier, Laugier and Bdrard had recourse to section of the resisting 
muscles. 

I have tried to discover to what degree inflammation augments 
the muscular resistance. In a rabbit whose thigh I had broken, the 
shortening being one centimetre, a weight of one kilogramme, by 
means of a double inclined plane, sufficed to give the limb its natural 
length, or in other words, to lengthen the shortened muscles by one 
centimetre. Two days after, a weight of three kilogrammes pro- 
duced a lengthening of only five millimetres. 



A TREATISE ON FRACTURES. 165 

In another rabbit whose leg I had broken, the experiment was at 
once more precise and more complete. I fastened in the tibia before 
the fracture two iron pins, eight centimetres apart; the first overlap- 
ping, which had amounted to two centimetres, was obviated by a 
weight of only 125 grammes. Two days afterwards, the shortening 
was the same ; and a weight of five kilogrammes only lengthened 
the limb to seven and two-thirds centimetres. The twelfth day, 
there was still the same amount of overlapping ; the fragments were 
still movable ; a weight of five kilogrammes had no effect. With 
nine and one-half kilogrammes, I procured a lengthening of five mil- 
limetres. I went on successively to twelve, fifteen and twenty kilo- 
grammes, without gaining more than one centimetre. Lastly, I tried 
twenty-five kilogrammes with no better success ; and then the tibia 
broke with the weight below the lower pin, which prevented my go- 
ing any further. Thus on the twelfth day I failed in the reduction, 
with a force two hundred times that which was sufficient on the first 
day, and about twelve times as much as the weight of the animal 
itself. 

From these facts and experiments, it may be concluded that in 
some cases either muscular spasm or inflammation may render reduc- 
tion impossible. 

But apart from the chances of failure, will such attempts be harm- 
less ? Hippocrates observed that, whatever their result might be, 
they always tended to excite inflammation ; it will be seen that this 
tendency is owing to the more or less irritated state of the parts, and 
to the violence employed. I once attempted, with the aid of assist- 
ants only, the reduction of a fracture of the cervix humeri, before 
the subsidence of the inflammation ; I failed, but there was developed 
around the lower fragment an amount of suppuration which destroyed 
the patient's life. I have seen also, in two hospitals in Paris, two 
nearly similar cases. The patient, in whom M. Laugier divided the 
tendo Achillis for a fracture of the leg, had abscesses not only at the 
point of section, but around the fragments. In two of those ope- 
rated on by M. A. BeVard, abscesses formed not at the seat of the 
division, but at the fracture ; and in all these three cases the issue 
was a fatal one. Now may we not justly charge this to the attempts 
made at reduction during the inflammatory stage ? And if any se- 
rious complication, such as a rupture of the integuments, is present 
to aggravate either inflammation or muscular spasm, it is not only sup- 
puration which ensues, but gangrene ; Boyer gives a striking exam- 
ple of this. "A young, strong, and robust man," says he, " in whom, 
after sufficiently enlarging the wound, I practised this reduction for 
a fracture of the femur, the upper fragment being stripped of peri- 
osteum for about two inches and a half, and protruding through the 
torn skin and muscles, did at first very well ; and I was pleased with 
the success of the efforts I had had to make in effecting the reduc- 



1GG A TREATISE ON FRACTURES. 

tion; but on the third day, inflammation of the limb came on, the 
tension became excessive, the swelling enormous; and the gangrene 
which supervened, in spite of all the resources of art, progressed so 
rapidly that it soon invaded the trunk and carried off the patient." 

[Dr. Pancoast has recently put in practice, in the Pennsylvania 
Hospital, the plan of sawing off the protruding ends of the bones, 
in two cases analogous to those now under discussion. One was the 
humerus of a boy ten or twelve years old, broken at the lower epi- 
physeal junction; the other involved both bones of the forearm of a 
man, who refused to submit to amputation. In both these cases the 
result is extremely satisfactory.] 

At other times, and especially when one has had to contend with 
muscular spasm, reduction may be followed by convulsions, delirium 
and even tetanus. Hippocrates has noted that in luxations of the 
ankle, which nearly always involve fractures, attempts at reduction 
made during the period of inflammation are more apt to induce con- 
vulsions when they succeed, than when they fail ; and when the con- 
vulsions come on after reduction, he adds, there is little hope of 
saving life. Sir A. Cooper gives two observations justifying this 
melancholy prognosis. In a man who had fracture of the fibula with 
luxation inward of the tibia, reduction was effected by main force in 
spite of the spasmodic contraction of the muscles. On the next day 
the limb was affected with constant spasm ; on the fourth day delirium 
also set in, and on the eighth death closed the scene. In another 
case tetanus appeared some days after reduction, and likewise carried 
off the patient. 

I say nothing of the danger of tearing muscles, vessels and nerves, 
which is doubtless a rare accident in reducing fractures; it seems 
however that a misfortune of this kind happened to Boyer himself. 
He had a fracture of the thigh to reduce in a vigorous subject, and 
did not succeed; he redoubled his efforts, and at last gained his end; 
but at the same time a large vessel was opened, giving rise to such 
frightful hemorrhage that the patient died under the hands of this 
great surgeon.* 

In fine, the two great contra-indications admitted by Larrey and 
Boyer, are only too well borne out by experience ; and it will doubt- 
less be readily agreed also that reduction should not be attempted 
without proper means both of effecting and of maintaining it. The 
only rational course then is, to put the limb in the most favorable 
position possible, and to combat the spasmodic irritation or the in- 
flammation by appropriate means. 

This course is however open to some objections which must be 
answered. Will not waiting too long give rise to the double danger 

* Roux, Disc, d'ouverture; Gaz. des Hopitaux, 1844, p. 535. 



A TREATISE ON FRACTURES. 167 

of the callus forming with the fragments in bad position, and of 
obliging nature to begin again, perhaps too late, all the work already 
done being useless ? Clinical observation triumphantly obviates these 
timid objections. Thus it is known that any considerable inflamma- 
tion always of itself delays the reparative process ; and we have else- 
where established that, consolidation being divided pretty accurately 
into three stages, the organization of the callus does not begin until 
the second. One may, therefore, if the case call for it, fearlessly 
allow the first period to elapse before proceeding to reduction. 

Another danger: will not the bony fragments, thus left to them- 
selves in the midst of the muscles, determine the suppuration which 
it is so important to avoid? This objection, I do not hesitate to 
say, is purely theoretical, and contradicted by the experience of 
all ages. In fractures, with overlapping, of the clavicle, humerus, 
femur, forearm and leg, we hardly ever obtain perfectly accurate 
reduction; and yet suppuration is excessively rare. I have not for 
my own part seen it occur at the seat of a simple fracture, except in 
just those cases in which the inflammation had been aggravated by 
improper attempts at reduction. 

Need we now discuss the question of the days, as proposed by 
Hippocrates? It is certain that the first day is generally the most 
favorable, and the second much less so. I have, however, cited one 
case in which reduction was impossible twelve hours after the frac- 
ture ; and Galen, criticising Hippocrates, justly remarks that if in- 
flammation is absent, reduction may be as properly attempted on the 
third or fourth, as on the first or second day. On the other hand; 
the seventh day is very far from being a certain limit to the duration 
of the inflammation ; but Hippocrates has given the true rule in such 
cases, viz., to wait for the inflammation to subside before attempting 
reduction. 

§ Y. — Of Apparatus. 

"When a fracture occurs without displacement, or after this latter 
has been overcome by the process of reduction, it is necessary to 
keep the fragments at perfect rest in their proper place, until con- 
solidation occurs; and this is the object of our apparatus. 

The forms of apparatus contrived for treating fractures in general 
may be arranged under six heads, viz., (1) ordinary splints; (2) im- 
movable apparatus; (3) plaster apparatus; (4) leather belts, straps, 
etc.; (5) hyponarthecia ; (6) apparatus for permanent extension. 

(1.) Ordinary Apparatus or Splints. — Following the chronological 
order in the exposition of this subject, we have first to speak of the 
apparatus used by Hippocrates ; and we think they merit the more 
careful description, since they received the approval not only of all 



108 A TREATISE ON FRACTURES. 

antiquity, but also of the principal surgeons of the sixteenth and 
seventeenth centuries. 

Hippocrates employed two forms of apparatus, one provisional 
and the other permanent. The former he applied at the outset; 
firsl covering the limb with cerate, he took a short bandage, and 
placing one end over the seat of fracture, made two or three turns 
loosely, so as not to cause too much pressure; thence he carried the 
bandage to the upper part of the limb, where it should end. A 
second roller, somewhat longer, was likewise applied, beginning at 
the seat of fracture, and going downward by wide spiral turns to 
the lower end of the limb, then again upward, passing by its own 
commencement, and ending where the first did. The direction in 
which these bandages were made to run varied with the nature of the 
displacement. If the fragments inclined toward the left, the turns 
were applied from left to right, and vice versd, so as to press the 
fragments in the opposite direction. 

These first portions of the apparatus received the name of hypo- 
desmides, or under-bandages. They were again covered by long 
compresses spread with cerate, arranged, as well as Ave can judge, 
parallel to the axis of the limb. In case of great diminution in 
the size of the limb toward its extremity, as in the forearm and leg, 
these compresses were carefully graduated so as to make the thick- 
ness the same throughout. The whole was finally made firm by two 
more bandages, epidesmata, one of which passed from left to right, 
the other from right to left; they surrounded the whole limb from 
below upward, except only some turns which had necessarily to pass 
downward. 

This apparatus was renewed every three days, an additional ban- 
dage being applied at each dressing, the number of bandages, how- 
ever, not being allowed to exceed six. 

Lastly, on the seventh day, or whenever the inflammation had 
entirely gone down, the splints, constituting the permanent dressing, 
were applied. These splints, probably composed of flat pieces hol- 
lowed in the middle, were put on over the preceding bandages, one, 
thicker than the rest, being on the side toward which the fragments 
projected ; they were to be of less extent than the bandages them- 
selves; thus for a fracture at the middle of the leg, they were not to 
go beyond, or perhaps even to reach, the malleoli or the condyles of 
the tibia. It appears that their number was quite considerable; 
according to Paulus iEgineta, there should be an interval of a finger's- 
breadth between them, so that they should make a sort of frame 
around the limb. They were held in place by very loose bands, so 
as not to add to the pressure already exercised by the bandages; in 
the treatise "De Laqueu' of Oribasius, may be found a representa- 
tion of a forearm thus surrounded by splints, in which the latter 



A TREATISE ON FRACTURES. 169 

are held together by a quite complicated knot called the " sailor's 
knot." 

If now we inquire what views led Hippocrates to the employment 
of this apparatus, we find no other use for the cerate spread over the 
limb and over the compresses, than to make the bandages hold better ; 
it was only an agglutinative. As to the bandages, the object of the 
first was to press away the blood from the seat of fracture, driving 
it back toward the upper part of the limb; the second, toward the 
lower part; and it was in order better to attain this end that the 
first few turns were made just at the seat of fracture, and that the 
pressure, stronger at that point, diminished upward and downward. 
It would seem that Hippocrates attributed to them likewise some 
agency in keeping the fragments in place. The compresses which 
came next, answered to our padding, insuring to the whole limb the 
pressure of the splints ; the outer bandages retained the compresses 
in place, and the splints formed a sort of external skeleton to the 
limb. The apparatus actually in use for fractures of the humerus 
represents very well that devised by Hippocrates, except that the 
cerate is discarded as valueless; but one bandage, or at most two, 
are employed, and importance is no longer attached to the mode of 
putting them on; the only indications we seek to fulfil are, to esta- 
blish an entirely equable pressure on the limb, and to fix firmly the 
compresses and splints. 

In dressing fractures attended with a wound or with necrosis, 
Hippocrates used the many-tailed bandage of Scultetus. 

The Arabians introduced two important modifications in splints. 
Rhazes recommended the use of shorter ones than those of the 
ancients: " There are cases," says he, "in which the reduction can- 
not be well maintained but with smaller splints, which fit the shape 
of the limb." He, however, supported these splints by others of the 
ordinary length. 

Avicenna adopted the small splints of Hhazes; but elongated, on 
the contrary, the outer ones. In the arm, for example, he applied 
four splints, to go beyond the shoulder and elbow; for the thigh he 
used two, strong, wide, and somewhat concave, extending from the 
pelvis to beyond the foot. These large splints had one real advan- 
tage, in keeping the foot in a proper direction; they were however 
far from being generally adopted. After Avicenna, I do not find 
that they are recommended until the eighteenth century; then first 
by Duverney, and later by Desault and Boyer, who finally reintro- 
duced them into ordinary practice. By reason of their breadth and 
length, they cannot be adapted to the shape of the limb, and hence 
some paddings are required to fill the interspaces. Avicenna re- 
commended for this purpose cushions, jmlvini, of the exact nature of 
which we are not informed; Duverney used compresses, and napkins 
folded lengthwise; Desault seems to have been the first to use the 



170 A TREATISE ON FRACTURES. 

l»:iL r > Staffed with oat-bran, so generally employed at the present 

It was doubtless the difficulty of procuring both the splints and 
their padding which led to the substitution of straw-compresses,* 
answering the same purpose at a much less expense. Guy de Chau- 
liac attributes them to a certain Maitre Pierre, who made them of 
long straws sowed up in a linen covering; A. Pare' put a strong 
stick of wood in the middle, to make them firmer; and finally, in the 
eighteenth century, the linen envelope was done away with, and the 
straws simply bound together with a string. J. L. Petit preferred 
the compresses of Maitre Pierre, the diameter of which was as much 
as two inches; Larrey adopted the straw tied up with a string; A. 
Kichtcr describes them as made in the same way, but with a willow- 
stick in the middle ; and in this latter form I have seen them still 
employed in Poland. f 

Finally, whether with the large splints or with the straw-com- 
presses, the bandages of Hippocrates and his mode of applying them 
were, generally speaking, retained. J. L. Petit and Duverney likewise 
recommended the placing of the first turns at the seat of fracture; 
only the theoretical object was changed; it was now to retain the 
nutritious juice and prevent deformity of the callus. But such an 
object could not be seriously aimed at; hence for the multiple ban- 
dages of Hippocrates were substituted first one of sufficient length, 
or even that of Scultetus; afterwards the bandage came to be com- 
menced at the lower extremity of the limb; and from the time of 
Pott this was, in England at least, the usual practice. 

But at the same time there commenced in the application of the 
bandages an innovation much more important, and one which, grad- 
ually gaining ground, has in our time reached its utmost extent. Until 
the eighteenth century the bandage never surpassed the length of the 
fractured bone, hardly even reaching to its extremities. J. L. Petit 
was the first to bring a turn of the bandage down from the forearm 
over the hand, and from the leg over the heel; but he made no 
change in reference to other fractures. Duverney bandaged the 
upper part of the forearm with the arm; and in the forearm he like- 
ly ise took in both the hand and the arm. Boyer went further, and 
in all fractures of the upper extremity made the bandage extend to 
the roots of the fingers; while, curiously enough, he limited himself 
in fractures of the leg to a mere loop under the foot, and in fractures 
of the thigh did not go below the knee. Lastly Larrey, going be- 
yond all these, enveloped each finger in a narrow bandage, for the 

* [This article having passed entirely out of use, no English word remains for 
it excepl the compound one employed above. The French term isfanon. Our 
pmk-lag scons to correspond most nearly to it.] 

t Pot a more complete account of straw-compresses, see my edition of A. 
Part, tome ii, p. 288. 



A TREATISE ON FRACTURES. 171 

upper extremity, and even in fractures of the cervix femoris, never 
omitted extending the bandage over the whole lower extremity. 

It would be entirely useless and out of place to describe here the 
mode of application of the roller, the bandage of Scultetus, or the 
eighteen-tailed bandage sometimes made use of; these are elemen- 
tary points as essential to the dressing of wounds as to the treatment 
of fractures. I shall likewise abstain here from detail as to the ap- 
plication of splints and compresses, which belong more appropriately 
to the history of each particular fracture. A more general and im- 
portant question should alone arrest our attention; to wit, what is 
their real utility. 

Boyer has attempted to show that the bandages intended to en- 
velope the limb serve infinitely little, if at all, to maintain the frag- 
ments in their natural position. Suppose, says he, a roller applied 
for a fracture of the humerus or of the femur, all the turns surround- 
ing each fragment are useless to prevent displacement; it is only 
those which are placed at the very seat of fracture, and hence act 
upon both the broken ends, which can serve to keep them in contact. 
Now to form an estimate of their inefficiency, it need only be 
observed that, allowing the bandage a width of three inches, an 
inch and a half only would bear on each fragment ; and that this 
power, so much the more feeble from the substance of the bandage 
being soft, flexible and unresisting, acts only through the thickness 
of the soft parts, hindering it from reaching the bone. The eighteen- 
tailed bandage is as inefficient as the roller, and the bandage of 
Scultetus perhaps even more so. 

This demonstration is not unanswerable; every bandage com- 
pressing the muscles circularly against the bone lessens to a certain 
degree the amount of separation of the fragments ; and when long com- 
presses are added, applied parallel to the axis of the limb, J. L. Petit 
goes so far as to say that they afford all the necessary support, and 
may even supersede splints. It may also be shown that a bandage, 
regularly applied to the broken arm of a dead body, gives the limb a 
notable degree of firmness. 

Boyer, therefore, has gone too far, or rather has omitted the most 
serious objection to bandages. This is, that practically, whatever may 
be the efficiency of their pressure at first, they become relaxed in the 
course of twenty-four hours, and all their good effect is lost ; and I 
think no surgeon would venture, on the authority of J. L. Petit, to 
rely exclusively on compresses. Slight as may be the tendency to 
lateral displacement, splints are indispensable ; but if splints are 
sufficient for this end, it remains to decide what is then the utility of 
bandages. 

Boyer answers that they are very useful, whether to retain the 
necessary topical applications, to prevent oedematous infiltration of 



172 A TREATISE ON FRACTURES. 

the limb, or lastly to soothe the irritability of the muscles by their 
writing the patient, so to speak, not to contract them. 
Such assertions hardly aeserve a serious refutation. As for topical 
remedies, it Lb evidently easier to apply them to a naked limb than to 
one Burronnded by compresses and bandages; as to oedema, ban- 
. with their circular pressure, are much more likely to deter- 
mine than to prevent it; and the other use attributed to them, of 
allaying muscular irritability, is so much the more problematical 
Bince at the end of twenty-four hours, as has just been stated, their 
pressure ceases entirely. 

Hence then, circular bandages alone cannot suffice for maintaining 
the fragments in place; and when splints are added to them, they 
become perfectly useless. Moreover, they have more than one in- 
jurious effect; applied to an inflamed limb, their relaxation is not 
always in proportion to the swelling, and then they exert a danger - 
ous pressure, which may bring on gangrene; aside from this danger, 
they conceal from the surgeon the state of things, which it is so much 
his interest to watch; if they cover only the upper part of the limb 
they become a cause of oedema, if they extend its whole length they 
favor stiffening of the joints. 

I know of but one case indicating their employment; it is when 
we need to protect the limb from the pressure of splints, using them 
as a sort of padding. With large splints, as in the lower limb, bags 
of oat-bran are infinitely more convenient; small splints, on the 
contrary, such as are applied to the arm, press too strongly on the 
skin, unless this is protected by a bandage. But even then the 
bandages need not extend beyond the length of the splints; this 
would be much more injurious than useful. In regard to this, I will 
merely repeat that from Hippocrates to Desault, inclusive, the lower 
portions of the limbs have been always left uncovered, and that 
Boyer himself, so careful to wrap the forearm and hand in fractures 
of the humerus, found no inconvenience in following the old plan 
in fractures of the femur. 

All the efficiency of the apparatus we shall study being thus con- 
centrated in the splints, let us see what conditions these should fulfil. 
Splints vary in respect to their composition, form, length, number 
and mode of application. 

The Bplints of the ancients were made of sticks or pieces of wood, 
hollowed along the middle; those of the Arabians, of Alcona wood, 
of olive, pomegranate, palm, fir, or willow-wood. Guy de Chauliac 
speaks of Bplints of horn, of leather and of iron; A. Pare' employed 
lead, tin, prepared leather, pasteboard and bark; Bromfield 
recommended whalebone; and Boyer indifferently wood, pasteboard 
and tin. 

The essential object of splints is to restore to the limb the solidity 



A TREATISE OX FRACTURES. 



173 



lost by the fracture, to replace as it were the internal skeleton by an 
external one. Hence the first quality requisite is a sufficient degree 
of firmness; but this firmness should vary with that of the bone in 
question, and according to the volume of the limb to be supported. 
Thus, in very young children, all fractures, even those of the thigh 
and leg, can be treated with pasteboard splints. In youth, paste- 
board is hardly suitable for fractures even of the arm and forearm, 
and must be very thick, or else double ; in adult age, its use is limited 
to fractures of the phalanges. 

The arm and forearm, however, short and not thick members, do 
not require very heavy support. Splints of light wood, such as lin- 
den, poplar, and especially fir, are generally sufficient, although oak 
and beech are preferable for very muscular persons. These hard 
and firm woods are required only for the large splints intended for 
the thigh and leg; and it is necessary to give even them sufficient 
thickness to prevent their bending. On the whole, pasteboard and 
wood, which are common and cheap materials, easily obtained and 
worked into the required form, appear to fulfil all the indications; 
splints of leather, horn, whalebone, or metal, are of no special value ; 
and bark is useful at most only in cases of necessity, and where 
nothing else can be had. 

[Very excellent immediate or auxiliary splints 
may be made by splitting a piece of some light 
wood into slips from six to ten or twelve inches 
long, one-quarter to one-half of an inch thick, 
and three-quarters of an inch to an inch wide ; 
these slips being then either glued side by side 
upon a piece of soft buckskin, as seen at a ; or 
fastened together by means of two strips of buck- 
skin, as shown at b. It is evident that more 
protection will be necessary for the patient's 
skin in the use of this h 

latter form of splint. 
The number, size and 
length of the slips 
should of course be 
varied according to the 
size and length of the 
limb, and in using the 
second form we should 
employ a firm bandage 
from the toes or fingers 
upward, that the venous 
circulation may not be 
impeded.] 





□□□□□nnn 

mjijcjornjo" 



171 A TREATISE ON FRACTURES. 

The/ortw of Splints varies little. They arc always smooth, flat strips, 
rounded at the ends. Hippocrates put one stronger than the rest op- 
the projection of the fragments; Guy de Chauliac advises that 
tlu-v Bhould be thicker in the middle than at either extremity, so as to 
cause a greater pressure. But where such pressure is necessary, the 
thickening of the splints, or a special splint thicker than the rest, 
would be insufficient; and compresses arranged within ordinary 
splints have the advantage of making the pressure at once more ex- 
actly and more gently. Boyer recommends making the small splints 
light and flexible, in order that they may adapt themselves to the 
shape of the limb; and to have those of tin slightly bent, so as to 
lit the convexity of the parts. This adjustment is almost impossible 
to obtain in wooden splints, without depriving them of all solidity; 
and besides that the tin splints are not very convenient to use, their 
1 tending is necessarily uniform, and cannot be adapted either to the 
form of different limbs, or to that of the same limb in different per- 
sons, nor lastly to that of the different aspects of the same limb; 
compresses or padding with ordinary splints will equalise the pressure 
much better. We have stated that Avicenna hollowed out a slight 
channel in his large splints for the lower limbs; but experience has 
shown that flat splints, with junk-bags, answer the purpose much 
better. 

There is perhaps but one exception to be made in this respect, 
in favor of pasteboard splints. When these are moistened before 
being applied, they become soft, and adapt themselves exactly to all 
points of the surface of the limb ; and when dried they preserve this 
form, while returning to their original solidity; unlike the uniform 
bending of the tin splint, this is a perfect moulding upon the limb 
itself and upon each of its faces. Only, in making use of this ma- 
terial, the wetting of the apparatus customary with some surgeons 
must be avoided, as lessening its solidity. 

The length of the splints deserves serious attention. There are 
four different lengths, to wit: (1) the small splints of Rhazes, adopted 
by Dupuytren under the name of immediate splints, much shorter 
than the diaphysis itself; (2) the splints of Hippocrates, reaching 
from one end of the diaphysis to the other, but not covering the epi- 
physes ; (3) the ordinary splints of Avicenna, exceeding the length 
of the fractured bone each way ; (4) lastly, the large splints of the 
Bame author, intended for the lower extremity only, and called by 
Dupuytren mediate splints. 

The immediate splints are intended to press on the fragments just 
at the seat of injury, and to obviate all lateral displacement. It may 
be seen, indeed, that splints exceeding the length of the bone would 
bear on the projecting epiphyses, and thus be too much raised from 
the shaft of the bone to exert upon it a uniform and sufficient pres- 
sure ; even those of Hippocrates, extending just over the diaphysis, 



A TREATISE ON FRACTURES. 175 

would not act upon the fracture if this occupied the most concave 
part of the bone. One might then substitute for immediate splints 
compresses of the same length, upon which the large splints should 
press ; but to act on the convexity of a bone, as, for instance, on 
the anterior face of the femur, the large splints press too much at 
the centre, and too little at the ends ; so that immediate splints be- 
come indispensable. But we must not forget that there is a special 
indication, in the absence of which they are useless ; they answer 
very well to obviate transverse displacement ; not so well in angular; 
still less in case of overlapping, and nothing or next to nothing in 
case of rotation. 

The splints of Hippocrates and the ordinary splints of Avicenna, 
which are less efficient in lateral displacements, are much more so in 
the angular ; but it is important to know which of them to choose ; 
or, in other words, whether the injured bone only is to be made im- 
movable, or the neighboring joints also. The answer to this inquiry 
cannot be the same in all cases. When an articulation cannot be 
left free without risk of deranging the fracture, it must be fixed by 
lengthening the splints ; as, for instance, in fractures of the pha- 
langes ; and so also in all fractures close to joints. If this danger 
does not exist, as in most fractures of the forearm, we may be con- 
tented with splints the length of the diaphyses, or at most, reaching 
from one joint to the other. 

[From a consideration of the extreme difficulty of preserving the 
muscles of any broken limb at perfect rest, and of the fact that so 
many of the muscles extend over two joints, as well as from the re- 
sults of experience, the general rule may be laid down that the limb 
should be well supported from its extremity as far up at least as the 
joint next above the fracture. Most English and American surgeons, 
we think, adhere to this line of practice.] 

Lastly, the mediate splints, designed almost exclusively for the 
lower extremity, to press on the foot from side to side, oppose rotary 
displacement as well as lateral flexion. 

From these considerations it follows that each sort of splint has 
its special office ; that our choice is to be guided by special indica- 
tions ; and that while in many cases all the splints used should be of 
the same length, there are often also cases requiring at once several 
splints of different lengths. 

The number of splints is not less important. There is never oc- 
casion for more than two mediate splints, provided, however, that 
the plane on which the limb rests is supported by a surface answering 
the purpose of a posterior splint, and hindering all flexion either an- 
teriorly or posteriorly. Boyer, I think, first advised the putting of 
another along the whole anterior face of the limb ; but he gives no 
reason for it, and I really can discover none. The immediate splints 
should always be at least two in number, so as to give mutual sup- 



1 Ti > A TREATISE ON FRACTURES. 

port : to confine the bone on all sides, there is rarely need of more 
than four. It is bo also with ordinary splints. Usually these are 
applied parallel, one on one side and the other on the other, always 
avoiding pressure upon the course of the principal vessels, so as not 
to hinder the circulation in the limb. 

No splinl should be applied to the naked skin. Pasteboard may 
be put OB over a simple bandage; for immediate, or ordinary splints, 
it is necessary to have long compresses, sometimes graduated, or 
carded cotton, charpie, or wool ; Guy de Chauliac used felt. I have 
already stated what sort of padding is required for mediate splints. 
The object of these interposed substances is not only to mitigate the 
pressure of the splints, but also to render it more equable, by filling 
up the depressions and hollows of the limb. 

Besides these general rules, the custom has prevailed of envelop- 
ing the mediate splints in a separate piece of linen, called by Desault 
drap-fanon, [splint-cloth,] and by Boyer £>orte-attettes. This is a 
cloth of about the same length as the splints, and broad enough to 
cover the posterior part of the limb, and enwrap each splint three or 
four times. Hence the limb lies entirely in the cloth, which forms a 
trough, and acts as a sort of posterior splint. This trough would 
really exist if the splints were wrapped with the posterior face of the 
cloth, so as to let the belly of the cloth hang from the upper edge of 
each splint ; but as they are wrapped with its anterior face, this ad- 
vantage, at any rate problematical, is almost entirely lost, and on 
the whole the splint-cloth only serves to prevent the splints from 
slipping forward ; an end which could certainly be attained with 
much less trouble. 

[In the New York Hospital, the splint-cloth is discarded in frac- 
tures of the thigh, and the practice is to employ three strips of wide 
bandage, each of which passes completely round each splint, and is 
tied like the ordinary confining strips. This plan not only saves a 
vast amount of time and trouble, (as any one will testify who has 
had half-a-dozen fractured thighs under treatment at once,) but when 
either strip becomes relaxed, it may be adjusted without taking off 
the apparatus, or disturbing the limb in any way.] 

When pasteboard splints are used, they are covered with what re- 
main- of the bandage, so as to be entirely concealed by the turns of 
the roller. Ordinary splints may be retained in place by the same 
means; or perhaps with bands made of ribbon about an inch wide, 
knotted on the external or on the anterior splint, and drawn tight 
enough to confine the fracture, without, however, causing any pain. 
I would remark here that the bands are as apt to become loose above 
as beneath the splints, and that the ribbons will, if too narrow, some- 
time, press painfully on parts unprotected by the splints. An excel- 
lent means of constriction, which I have often employed, consists of 



A TREATISE ON FRACTURES. 177 

two or three strips of adhesive plaster, varying in width according to 
the requirements of the case, and long enough to go round the limb 
once and a half or twice. They are not liable to become relaxed ; 
when the limb emaciates, they may be tightened up as easily as rib- 
bons ; and lastly, the same strips may be used throughout the 
treatment. 

There must be added here a few words on the subject of straw- 
compresses, since some surgeons still use them. Desault especially 
opposed them violently ; he accused them of sliding backward and 
forward, thus leaving the leg unsupported and the foot free to fall 
outward. In this respect, we would say that they support the limb 
as well as the large, splints, when there is no tendency to displace- 
ment ; if this tendency does exist, either one would be insufficient, 
and the use of immediate splints becomes necessary. As to their 
slipping backward and forward, they will do so if not thick enough, 
but so also will splints, if too narrow. Thick compresses, and wide 
splints, are equally free from this fault. Moreover, the straw-com- 
presses as prepared by J. L. Petit, of long straws and without rods, 
two inches thick, and not very firm, so as to flatten and mould them- 
selves to the limb, are less likely to slip than splints. We prefer, 
however, the latter, as being more solid, and as by the bran-bags 
their pressure is rendered at once softer and more exact ; but where 
the surgeon cannot obtain splints, the straw-compresses afford him a 
resource of no small value. 

(2.) Immovable Apparatus. — By this we mean bandages surround- 
ing the limb, and saturated with a liquid by means of which they 
acquire when dried a great degree of solidity. Their general deno- 
mination is therefore not derived from their composition, but from 
the rule adopted by their partisans of allowing them to remain until 
consolidation is complete. 

We find a kind of glue, made with gum or starch, recommended 
by Hippocrates for fractures of the nose, and by Celsus for fractures 
of the jaw. But it appears from a passage in Rhazes, that it was 
an Arabian surgeon named Albugerig who extended the plan to frac- 
tures generally. Later, Albucasis employed cakes of tow steeped in 
a glue made of meal and albumen ; lastly, albumen alone was used 
by the followers of the Arabians ; by some with tow, and by others 
with bandages. These albuminated apparatuses were transmitted 
from age to age, and we find them described by A. Pare', Fabricius 
of Acquapendente, Wiseman, Cheselden, Moscati and Larrey. It 
should be observed, however, that splints were always used in addi- 
tion ; Wiseman and Cheselden appear to have first recognised the 
fact that when the apparatus dried the splints became useless. In 
our own times, in 188-4, M. Seutin substituted starch for albumen; 
M. Velpeau, in 1837, dextrine for starch; M. Laugier, in 1838, 

12 



1X1 A TREATISE ON FRACTURES. 

paper for the compresses; not to speak of other insignificant modi- 
ficat: 

We have now to discuss, first, the nature of the solidifying mix- 
tures, and afterwards the composition and mode of application of the 
bandage. 

A solution of gum may be made in cold, but much more quickly 
in boiling water ; it is very little used at present, although in case of 
aity it answers very well in place of other substances. In order 
to make use of the whites of eggs, they are tempered and beaten up 
with water, so as to mix them with it as thoroughly as possible ; Lar- 
rey added a solution of camphor in brandy, and lead-water; but 
these are useless, and may as well be omitted. .The glue from starch 
is obtained by boiling; it is merely a jelly. The solution of dextrine 
may be variously prepared. Generally we begin by putting in a 
vessel a suitable quantity of dextrine, viz., about 500 grammes [about 
one and one-third pounds Troy] for a fracture of the thigh ; 200 for 
the leg, and the same for a fracture of the arm or forearm. We 
pour upon this alcohol or camphorated brandy, and work the mixture 
until it has acquired the consistence of honey ; this done, we add a 
sufficient quantity of hot water ; and after one or two minutes' shak- 
ing, the solution is ready for use. According to M. F. d'Arcet, the 
proportions most favorable at once to the drying and solidifying of 
the apparatus are, 100 parts dextrine, 60 of camphorated brandy, 
and 50 of water. f 

The mode of application varies, but this variation depends much 
less on the nature of the solution employed than on the particular 
views of each surgeon. 

Larrey commenced by laying along the fractured limb some nar- 
row compresses, dipped in the liquid ; afterwards he enveloped the 
whole in an eighteen-tailed bandage similarly prepared, beginning 
with the lowest turns. Above this bandage were placed, according 
to the requirements of the case, the paddings, consisting generally 
of cushions or wads of tow ; these being in place, the apparatus was 

* H. Larrey, Traitement des fract. des membres par Vappareil inamovible ; 

These inaug., Paris, 1832 ; Seutin, Du bandage amidonne', on Recueil de toutes 

ces composes sur ce bandage, etc., Bruxellcs, 1840 ; Velpeau, Note sur un 

■■■> }>>/fect. de I'appareil inamovible; Bulletin de TJie'rapeutique, Fev., 

1838; Aguilhon, Mem. sur le trait, des fract. par Vappar. inamov. en papier 

amidonne cU M. Laugier ; Gazette Me'dicale, Octob., 1838. 

tAs regards dextrine, an important point was recently brought practically 
under my notice, viz., that as sold in the shops, it is often unfit for making an 
agglutinative mixture; it forms lumps with alcohol, as starch does with cold 
water, without cohering ; and twice in succession I have been obliged to change 
tlio supply at the Hdpital Saint Antoine. The dextrine thus deteriorated is 
whiter and less saccharine ; it crepitates more in the fingers ; and on pouring a 
f.w drops of tincture of iodine into the solution, there is produced a violet tint, 
indicating the presence of fecula ; while true dextrine, treated with iodine, gives 
a vinous red, or the color of onion-peel. 



A TREATISE ON FRACTURES. 179 

freely moistened with the remainder of the solution. Lastly came 
the bran-bags, the straw-compresses wrapped in their cloth, and the 
bands to keep all in place. These compresses were kept applied as 
long as the bandage itself. 

M. Seutin makes his apparatus of separate bands and compresses, 
as in the so-called bandage of Scultetus ; sometimes with rollers, and 
lastly with pasteboard splints. These latter are straight or bent, 
according to the appearance and form of the part ; torn rather than 
cut, so that their edges may be more yielding ; having openings, 
likewise torn, corresponding to the osseous prominences ; and are 
either passed quickly through hot water, or held some minutes in 
cold, to make them supple. What distinguishes M. Seutin's method 
particularly, is that he does not- soak his apparatus ; he lays on the 
glue above it, with a brush or with the hand. Thus he begins by 
covering the limb, dry, with a layer of bandage or of compresses, 
and over this he spreads the mixture with the brush or hand ; the 
next layer of bandage thus becomes smeared on the inside in being 
put on, and is again spread with the jelly on its outer surface. At 
this stage the osseous prominences are protected by covering them 
with wadding, charpie, " cat-tail"-down, agaric, etc.; over this are 
applied the pasteboard splints, themselves in turn smeared with the 
mixture ; they are kept in place by new compresses and bandages, 
and finally the last envelope is thoroughly starched. Thirty or forty 
hours are required for complete drying. In order, meanwhile, to 
keep the fragments in good position, M. Seutin adds a provisional 
apparatus, preferring an old mould from a previously cured fracture. 

M. Velpeau prefers rollers to all other forms of bandage, and 
soaks them beforehand. M. F. d'Arcet has contrived for this pur- 
pose a little vessel like a dyer's vat ; but this has been discarded, 
and the bandages are unrolled and rolled with the fingers, just as 
usual. The limb being previously entirely enveloped in a dry roller, 
its hollows filled with compresses, the bandage smeared with dextrine 
is applied spirally from the extremity of the limb up to the trunk, 
as if for the purpose of compression, but avoiding reverses as much 
as possible ; this roller being exhausted, the external surface is 
smeared with what remains of the solution, the hand being passed 
from above downward or from below upward, according as the spirals 
run. There is thus but one bandage used, and no splints of any 
kind. Sometimes, however, M. Velpeau adds pasteboard splints ; 
quite commonly, also, he puts on wooden splints provisionally, on the 
outside, removing them after complete desiccation has occurred. This 
latter may be hastened by suspending the limb from a hoop, by two 
or three bands smeared with cerate to prevent their becoming glued 
to the apparatus. 

Lastly, M. Laugier, as has been said, uses neither compresses nor 
bandages; he employs instead tarred paper (papier goudronne,) which 



180 A TREATISE ON FRACTURES. 

b Pound in the Bhops in the form of thin but solid sheets, sixty-five by 
ninety centimetres; his glue is composed of starch. The paper is cut 
into .'trip-, tour or five centimetres wide, by forty-five to sixty long, so 
a> to 20 at least once and a half round the limb; the longest serve to 
envelope the foot or hand, and to increase the firmness of the apparatus, 
by holding together others longitudinally disposed. In all, we must 
have strips enough to make, each one being covered in three-fourths 
of its width, four complete envelopes to the limb. They are first ar- 
ranged upon a pillow protected by a cloth, and smeared with the 
paste on both sides. Those for the upper part of the limb are first 
applied, and covered successively by the lower ones ; over this first 
layer is applied the second, then the third, then the fourth, each 
layer being carefully strengthened by longitudinal strips, as was 
before said. It is very important to lose no time when the strips are 
once soaked, lest the paper, becoming too moist, should give way in 
the surgeon's hands. In summer-time, twelve hours are enough for 
the drying of the apparatus ; in winter it takes twenty-four hours, 
and it is well then also to put along the sides of the limb hot bricks, 
or stone bottles full of boiling water. Meanwhile, the limb should 
be so placed that its direction cannot change, and the patient should 
avoid making the slightest movement. M. Laugier sometimes ap- 
plies also provisional splints; and lastly, he prevents the foot from 
falling over by means of a sling, the ends of which are fastened above 
to the hoop. 

"We see that MM. Seutin and Velpeau take care to cover the skin 
with a layer of dry bandage or compresses, to protect it from the 
injurious contact of the dried apparatus. If the limb is large and 
fleshy, this may suffice ; if there are very marked osseous promi- 
nences, it is well to cover them specially with wadding or agaric ; but 
when the limb is thin and the skin delicate, I take care to increase the 
number of dry compresses ; and I have discovered the usefulness 
also of the precaution of Hugues de Lucques, who in fractures of the 
leg, for instance, covered the knee with dry tow or linen, to avoid the 
pressure of the upper edge of the apparatus. These dry compresses 
serve also to absorb the cutaneous transpiration, and to prevent the 
contact of the adhesive matter with the skin. M. Laugier omits this 
ition ; it would seem, however, that some of his patients suf- 
fered from uneasiness, and that on removing the apparatus the skin 
was found reddened, or even excoriated. Larrey, so far from keep- 
ing the limb dry, moistened the apparatus, during the first few days, 
either with his albuminous mixture, or with camphorated vinegar and 
water ; but we must note the difference between these liquids, the 
latter being really an evaporating lotion, and employed as such by 
Larrey, with the object of cooling the limb. 

The apparatus, once in place, is generally left to itself; but here 
the practice of M. Seutin differs essentially from that of others. 



A TREATISE ON FRACTURES. 181 

From the second to the fourth day, and much sooner if he feels 
at all uneasy as to the state of the limb, M. Seutin opens his ap- 
paratus from above downward, so as to be able to separate the two 
halves like valves ; using very strong blunt-pointed scissors or shears. 
This section made, if the apparatus fulfils the indications, it is reap- 
plied with a starched bandage. If it is too tight, it is enlarged by 
leaving a suitable space between the edges, to be filled up by a small 
slip of pasteboard, moistened and fitted on the skin ; if there is too 
much pressure anywhere, by an irregular turn of the bandage, or by 
a wrong arrangement of the pasteboard, the apparatus is softened at 
that point with hot water, the bandage or splint set right, and a 
delicate layer of wadding applied over the skin; the state of the 
parts is daily examined, until they may safely be left to themselves. 
If afterwards the apparatus becomes too large, a longitudinal strip 
is cut away, and the edges of the section brought together. In any 
of these cases, a roller, starched and applied externally, renews the 
firmness of the apparatus. 

This danger of the apparatus becoming too large, from diminution 
of the swelling in the soft parts or from atrophy of the limb, is common 
to all these forms of treatment, and has engaged the attention of all 
their adherents. Larrey merely advises tightening the bands above 
the compresses; but M. Yelpeau prefers renewing the bandages 
throughout, which is doubtless the safer plan. As to some other 
propositions, such as to pour in plaster between the splints and the 
limb, to fill up the interspaces, it would probably be superfluous to 
mention them. 

But the solid nature of these moulds in which we envelope the 
limb, makes it necessary to describe the mode of removing them. 
There is in this respect a great difference among the liquids em- 
ployed. Diluted albumen, although giving a bandage solidity enough, 
adheres less than jelly or dextrine, and usually allows of stripping 
off the compresses one after the other. It is but seldom, except 
when dried pus has contributed to harden the bandage, that one is 
obliged to cut it from one end to the other. The shears of M. Seutin 
are extremely convenient for this; Larrey used ordinary strong 
scissors, dividing layer by layer, and always carefully avoiding any 
shock or jerk to the limb. Starch is more resisting; and in order to 
strip off the bandages stiffened with it, it is necessary to moisten 
them with hot water. But dextrine is still more obstinate; the least 
attempt to separate the layers breaks them almost like glass, and 
the limb must be subjected to a complete and long-continued soaking. 

If now we examine the mode of action of these different forms of 
apparatus, it is in the first place evident that before drying they can 
only act like ordinary bandages, and hence can avail nothing in 
maintaining reduction. We must therefore, during one or two days, 
make use of some other means for this, such as the compresses of 



L82 A TREATISE ON FRACTURES. 

Larrey, the moulds of M. Seutin, the provisional splints of MM. 
Velpeau and Laugier. Once solidified, all these external applica- 
tionfi become useless, and M. Seutin has justly discarded them. But 
are his pasteboard splints really necessary? Before the drying, they 
ar^ moist, and of course without firmness; after it, they are super- 
iluous. M. Velpeau has therefore happily simplified the apparatus 
by omitting tjieni. 

But if the i in movable apparatuses derive all their efficiency, before 
their drying, from external supports, they cannot, after it, have any 
more efficiency than these had; for in drying they acquire only the 
capacity of replacing them. Now these compresses, these splints, 
these hardened moulds, extended along the limb, may indeed pre- 
vent angular or rotary displacement, but can avail nothing against 
tranverse displacement or overlapping; which is true also of our 
ordinary immovable apparatuses. Nor is this all; they hinder the 
rotation of the foot, in fractures of the thigh for instance, simply 
by holding the limb extended, and enveloping it down to the toes; 
and this is why Larrey, who carried his bandage only to tKe heel, 
was obliged to use straw-compresses during the whole of his treat- 
ment. So also, MM. Seutin, Velpeau, and Laugier, take in the 
whole of the lower extremity ; and they even, but with less reason, 
carry their dressings down to the ends of the fingers in fractures of 
the upper extremity. I have already stated how much risk this 
mode of treatment involves of stiffening of the joints, and I shall 
have occasion more than once to recur to it. 

This plan is open to other objections; as, for instance, that the 
apparatus exerts too much pressure' at first, and afterwards becomes 
too large; and that, during the whole progress of the case, it con- 
ceals the state of the limb from the surgeon. These different points 
will be discussed to more purpose when we come to speak of the 
choice of an apparatus, and the times of applying and renewing it. 

As to the comparative value of the different elements of these 
forms of apparatus, I employ either of the mixtures proposed that 
may be at hand; and so far have found no reason for any preference. 
The manner of soaking the bandages is not of much more importance.. 
Lastly, the use of rollers is certainly preferable in fractures of the 
upper extremity ; but for those of the lower, the bandage of Scultetus, 
or the compresses, have the incontestable advantage of being put on 
without disturbing the limb. Of the paper splints I have no more to 
KCept that they would afford a valuable resource in case of a 
scarcity of linen. 

(3.) Of the Plaster Apparatus. — This form of apparatus dates as 
for back as the Arabians. Albugerig, the writer already spoken of, 
besides gum and rice-water, employed powdered chalk or calcined 
plaster; and another surgeon, called by Rhazes Athuriscus, mixed 
chalk and white of eggs, to obtain a more solid mortar. It appears 



A TREATISE ON FRACTURES. 183 

that this use of plaster was retained in the east; Eaton, an English 
consul at Bassora, about the close of the last century, writes that he 
saw a fracture of the leg cured in this manner, for which a European 
surgeon had proposed amputation. It seems that it was common in 
Upper Egypt at the time of the Erench expedition to that country, 
and Froriep attributed it to the Moors of Northern Africa. In 
Europe, I find it employed first by Hendriksz, at the hospital of 
Groningen, in 1814; some years later, by Hubenthal, who believed 
himself to be the inventor; but these attempts had been forgotten, 
when Keyl, having employed plaster at the Charity Hospital in 
Berlin, in 1828, succeeded at last in calling general attention to it.* 

There are several modes of constructing this apparatus. Dieffen- 
bach invented a peculiar box for running the plaster, which I have 
tried, but found very inconvenient. Besides, the necessity of using 
the hammer and chisel to break up the moulds when they are in one 
piece, involves shocks which might injure a recently consolidated 
callus. The simplest mode is that of Hubenthal; but the unsized 
paper employed by him answers no useful purpose. 

He begins by rubbing the limb with warm oil, to prevent the hairs 
from sticking, and by covering the lower part of the limb with a 
paste made of equal parts of plaster and unsized paper, reduced to a 
mash with a sufficient quantity of water. Afterwards, having a 
trough of pasteboard held under the limb, he fills with the paste, at 
one gush, the entire space between the trough and the limb, so as to 
envelope half the thickness of the latter. This done, and before the 
paste has solidified, he scrapes with a knife or spatula the two edges 
of this lower half of the mould, thus making them entirely smooth; 
he also cuts several notches, so as more firmly to attach the upper 
half. These edges, with the notches, being oiled so as to prevent too 
firm an adhesion, he finishes by laying the paste over the upper half 
of the limb. The mould is thus formed of two halves, easily sepa- 
rated in case of need, exactly fitted to one another, and retained in 
place by bandages. 

There is but one defect in this description. The mixture would 
run out at each end of the pasteboard trough, unless in some way 
prevented; hence it is well to surround the limb with a towel of 
sufficient thickness, above and below, and to make the pasteboard 
rest against these temporar}^ barriers. Common cerate may also be 
substituted for the oil in the preparatory greasing. 

* See Med. Commentaries, decade ii, vol. ix, p. 79 ; Seutin, Du bandage 
amidonne, etc.. p. 17; Hubenthal, Nouv. manure de traiter les fractures ; 
Xouveau journal de med., tome v, p. 210 ; Muttray, De cruribus fractis gypso 
liquef. curandis; Diss, inaug., Berlin, 1831 ; A. L. Richter, Abhandlungen aus 
dem Griiete der PraktiscKen Med. mid Chirurgie, Berlin, 1832. I have given 
an extract from these last two works in the Gaz. Medicate, 1832, p. 525 ; and 
1833, p. 285* 



184 A TREATISE ON FRACTURES. 

The Arabian apparatus, as seen in use by Eaton, differed little 
from this; only there were placed in the lower half of the mould 
Bevera] hollow reeds, to favor the drying, and doubtless also to di- 
minish the heat developed by the plaster. This precaution has been 
generally deemed superfluous. But in the upper half of the mould, 
the Arabian surgeon had made a channel along the spine of the 
tibia, bo as to apply evaporating lotions, and also so as to have the 
fracture in sight during the treatment. Dieffenbach, who made his 
mould in one piece, nevertheless left uncovered part of the anterior 
surface of the leg; and A. Richter, adopting this modification while 
making his mould in two pieces, thus returned almost exactly to the 
Arabian method. 

So far we have plainly shown the mode of applying the mass of 
plaster; but there are some essential points connected with its pre- 
paration. 

The plaster used is the common pulverized. The white is prefer- 
able to the gray, which is mixed with foreign matters, and makes a 
less homogeneous mass. It should not be recently calcined, nor in 
too fine a powder, lest too great a heat should be generated in its 
solidification. To temper it, it should be put little by little in a 
proper quantity of spring water, with constant stirring. The mass 
is just right when it is of the consistence of thick cream, and there is 
no water on the surface. If the plaster be added in excess, it will 
not be sufficiently liquid, and will develope too much heat in setting; 
hence it is well to let a little of it run beforehand, by way of trial. 
Lastly, the whole quantity required must be mixed at once, a fresh 
mass not easily uniting with a portion already solidified; and it 
should be prepared at the very moment when it is to be used, as it 
sets quickly, and then loses its facility of adaptation to the limb. 

The advantages of this apparatus, at the first glance, are striking ; 
cheapness, easy application, permanence and solidity, equable pres- 
sure ; besides which it allows of the fracture being always under ob- 
servation, and of applying suitable topical remedies, without fear of 
its becoming disarranged or soiled. 

But on further examination, it is found to be open to quite serious 
objections. In the first place, the weight of the apparatus, which 
mu<t at least hinder it from being generally applied. This is, how- 
ever, lcs3 of an inconvenience than it would at first seem. It has 
been feared that by preventing the slightest movement, the appa- 
ratus would greatly fatigue the patient; experience has completely 
done away with this idea. The surgeons of Berlin believed that the 
use of this method should be confined to fractures of the leg; but 
Hubenthal had previously treated in this way fractures of the fore- 
arm, of the hand, of the clavicle, and, in fine, every fracture but that 
of the leg. for which he had no opportunity. 

We have already said that the plaster, in setting, developes a 



A TREATISE ON FRACTURES. 185 

pretty high heat. t Muttray asserts that it is hut slight, and that a 
larger quantity of plaster gives out less than a smaller. This latter 
assertion is contradicted hy A. Richter; and for my own part, in a 
case in which I applied the plaster according to Dieffenbach's mode, 
in a single mass of considerable thickness, so intense a heat was de- 
veloped that the patient, a stout and courageous man, complained 
much of it for several minutes. It must be, however, that there are 
variations in this respect, the cause of which is not well known ; for 
M. Woillez, having plunged a thermometer in a vase containing a 
litre of fresh plaster, observed a very gradual rise of temperature 
during an hour, the greatest height not being as much as 14° Reau- 
mur. [61° Fahr.] 

Another and more serious objection is derived from the expansive 
force of the plaster, which in setting may compress the limb too 
tightly. Muttray says that this is hardly perceptible, and would 
have no bad result. M. Woillez adds that it takes place outward, 
and has even the effect of enlarging the mould; so that, he adds, in 
spite of the immobility of the limb, there is always a slight space left 
between the limb and the plaster, during the solidification of the 
latter; and of this he cites several cases. The same author, how- 
ever, explains this phenomenon differently a little further on. The 
leg is held suspended by assistants while the plaster is running, and 
the calf is free; while afterwards, when the limb is left to its own 
weight, the calf is flattened out, leaving thus in front a considerable 
space. M. Woillez thought this space ought to be filled by pouring 
in fresh plaster ; but on doing so the severe pains induced by the 
excessive pressure obliged him to break the mould. For my own 
part, in the patient before mentioned, who had a compound fracture 
of the leg, I applied the plaster on the eleventh day from the acci- 
dent, the limb being in the most satisfactory condition. All the 
anterior part of the leg was left bare ; I entirely covered the knee 
and the ankle. Next day, a slight but painful swelling involved the 
integuments along the edges of the plaster; I removed these edges, 
which seemed to exert too much pressure. The second day, the 
same thing occurred; ascribing it to the plaster around the knee, I 
removed the upper half of this. The third day, it was necessary to 
do the same by the ankle, and moreover, to hollow out with a chisel 
the sides of the mould, which were still too tight ; and the same pro- 
ceeding was called for on the ensuing days, till at last the mould 
was broken in pieces, and replaced by an albuminated apparatus. 
M. Woillez has seen a similar case; whence he concludes that the 
plaster cannot be borne by subjects who are very sensitive.* I 
think it important, therefore, at least in cases where there has been 

* "Woillez, Obs. et Riflex. sur Vemploi du pldtre couU ; Gaz. Medicate, 1836, 
p. 353. 



186 A TREATISE ON FRACTURES. 

some previous inflammation, to surround the limb with some folded 
compresses before applying the plaster; we thus' avoid at once the 
immediate pressure and the excessive sensation of heat; and I have 
been satisfied with the results of this precaution. 

A. Uicliter has also remarked that the prolonged retention of the 
limb in the mould, by confining the perspiration, makes the skin 
tender, and even causes superficial excoriations; for the prevention 
of this he advises moistening the limb with lead-water, and, after 
the fourth week, putting a compress between it and the mould. The 
Bmearing with oil or cerate, necessary in the ordinary methods, 
would tend to bring on such accidents ; the interposition of com- 
presses from the beginning, according to my plan, renders the 
smearing unnecessary, and has the advantage of obviating all the 
dangers at once.* 

There have been, recently, other attempts at inventing petrifiable 
dressings, which seem based on those of the Arabians; thus for in- 
stance, M. Laf argue proposed to mix equal portions of plaster and 
of starch. Of these I have nothing special to say. 

(5.) Of Cuirasses. — I embrace under this head all forms of appa- 
ratus intended to completely envelope the fractured limb. 

Wiseman is the first author who mentions them; their use was 
then confined to fractures with wounds. Some, easily made ex- 
temporaneously, were formed of two troughs, a superior and an 
inferior, of pasteboard, copper, or tin, held together by three bands; 
others, kept on hand, were softly padded on the inside, and pro- 
vided with an opening for the dressing of the wound. J. L. Petit 
saw such cuirasses employed; and Heister describes a copper one, 
composed of three pieces united by hinges, and held in place by 
bands. But all these attempts are small compared with the great 
machine of La Faye ; it was made of tin, and was therefore light, 
but not costly; it consisted of longitudinal pieces joined together by 
hinges, so as to be laid flat beneath the limb; hence it was easy of 
application; it confined at once the pelvis, thigh, leg, and foot, 
hence it insured complete immobility; but it could if necessary be 
divided so as to make a special receptacle for the knee or leg, and 
hence was adapted to any fracture of the lower extremity. Lastly, 
La Faye would even adapt it to all patients, great or small ; therefore 
for a short limb he made the pieces slide into one another; for a 
thin limb he made one part overlap the other, and had the bands 
tied tighter. There were still wanting openings for the dressing of 
wounds; Coutavoz added these, and then it would seem as if no 
room were left for improvement, f 

The majority of the succeeding inventions were much inferior to 

* A. Richtor, loc. cit. 

f Mtm. da VAcad. de Chirurgie, tome ii, p. 403 et seq. 



A TREATISE ON FRACTURES. 187 

this. The copper buskin of Ravaton is clumsy; the wooden splints 
of Gooch, glued to a leather band and fastened around the limb, are 
deficient in solidity. Lastly, quite recently, M. Bonnet of Lyons 
has had prepared, first in iron wire, and afterwards in pasteboard 
moulded on wooden mannikins and then strengthened with iron 
bands, a cuirass much more complete than that of La Faye. It en- 
velopes not only one, but both legs, and not only the pelvis, but the 
trunk up to the armpits. Doubtless immobility is thus still more 
effectually secured; but the new apparatus, having only a single 
opening in front, is less easily applied than that of La Faye, cannot 
be so well adjusted on limbs of different lengths, and lastly is only 
suited to fractures of the femur. M. Bonnet himself confesses that 
the majority of simple fractures of the leg or thigh are far from 
calling for its use. 

The upper extremity was much longer neglected by mechanicians. 
Ravaton however, conceived the idea of inclosing the arm in a cop- 
per cuirass called by him his contentif; and M. Bonnet has con- 
structed another, far more complicated, enveloping at once half the 
thorax, the arm, forearm and hand. It should be added that the 
cuirass of the right side cannot be used for the left; and a special 
one is required for each patient, since it must be modeled on the 
exact shape of the body.* 

"When we seek to estimate the utility of these machines, we see at 
once that the simpler they are, the less they can rival those ordinary 
apparatuses which have as much or more efficiency; and that the 
more complicated they are, the less chance they have of being gene- 
rally adopted in practice. The ingenious invention of La Faye has 
for a long time existed only in recollection. It would hardly then 
seem worth while to dwell upon the description of things consigned 
to oblivion. And yet when they have been called forth, not merely 
for the convenience of the patient or the surgeon, but to fulfil some 
special indication, we should notice that this indication does not dis- 
appear with them. I cannot, for instance, perceive any other real 
advantage in the cuirasses of M. Bonnet, than that they fix the pelvis 
or the shoulder; but this is sometimes an essential point, recognised 
by others, and one to which we shall recur in connection with frac- 
tures of the humerus and femur. 

(5.) Of Hyponarthecic Apparatus. — [This term, derived from 
5no f under, and vapthjg, a splint, has no parallel word in English, 
and has therefore been merely Anglicised. Any form of apparatus 
whose main feature consists in its affording a bed for the injured 
limb, would come properly under this head.] — We come now to an- 

* Bonnet, Mem. sur les fractures du femur, etc. ; Gaz. Me'dieale, Aug. and 
Sept.. 1639 ; Sur des appareils nouveaux, etc. ; Bulletin de The'rapeutique, 
tome xviii ; and Compte-rendu du Service Chir. de VHotel-Dieu de Lyon, Lyons, 
1844, p. 26. 



188 A TREATISE ON FRACTURES. 

Other form of dressings, in which at least half the limb is left 
exposed, or even the entire limb, all but the portion resting on the 
sustaining plane They are very various, comprising troughs, boxes, 
cushions, dings, hoards, double inclined planes, and fracture-beds ; 
and their history has hitherto remained one of the most confused 
departments of surgery. 

Troughs date as far back as the time of Hippocrates; they were 
placed according to necessity under the leg, the thigh, and even 
under the pelvis; and some surgeons added to them the foot-board. 
They were at first made of wood; afterwards of clay; and although 
usually the limb was deposited in them only when enveloped in band- 
ages and splints, Paulus iEgineta informs us that in fractures ac- 
companied by wounds, some surgeons used them alone. A. Pare* 
speaks of troughs for the upper extremity, made of lead, paste- 
board and tin; and credits himself with the invention of a tin one 
for the leg. In the eighteenth century, Ravaton made them of 
wood, copper, and hammered iron, for fractures of the thigh and 
of the leg; the limb was retained in place in them by iron rings; 
but their use rendered that of any other apparatus unnecessary. 
Assalini, in 1812, advised making them of varnished tin, either for 
the thigh or for the leg, with straps and buckles to confine the limb. 
So far, all the troughs for the lower extremity were straight, so as 
to hold it extended; in 1825, Dr. Nathan Smith separated the trough 
for the leg from that for the thigh, jointing them at the knee so as 
to give the limb any degree of flexion which might be judged pro- 
per. M. Munaret contrived, in 1835, an analogous apparatus, with 
the addition of slinging it; he afterwards gave this up, returning to 
the simple suspended board. Lastly, M. Mayor has recently recom- 
mended one made of iron wire ; I have seen also those of M. Cambrai, 
made of zinc ; the material used is however of but slight importance.* 

Boxes differ from troughs in consisting of a bottom joined to two 
flat parallel sides. Galen described one under the name of glosso- 
comum, and says that it should be so narrow as when lined with 
wool to hold the limb quite firmly, allowing it no motion. But this 
plan soon fell into disuse; I find no more mention of it until it is 
spoken of by A. Pare*, who calls the apparatus guesses. J. L. Petit 
describes the box in common use before his time as composed of a 
foot-hoard, a bottom and two sides; each of these was padded within, 
and they were so united by hinges as to be taken apart at will. But 
he himself, wishing to make this more complete, devised another, 
which constitutes an era in the history of this form of apparatus. 
First, instead of wood, the bottom was made of ticking stretched in 

*N. Smith, New York Med. and Phys. Journal, Oct. and Dec, 1825; 
(quoted l>y A. Richter;) Munaret, Lettres Chirurgicales d M. Mayor, etc.'; 
Qaz. M&duxUe, 1835, pp. 433 and 673; and Du Me'decin de Campagne, Paris, 
1837, tome ii, p. 78. 



A TEEATISE ON FRACTURES. 189 

a frame, forming a sort of bed of webbing, which was prolonged 
under the thigh, and sloped here like a double inclined plane. Again, 
the whole box was jointed at the upper end to another frame resting 
on the bed, and the lower end could be raised up or let down on this 
frame by a kind of hook, so as to change at will the elevation of the 
limb. The fate of this box may well impress the observer; it was, 
according to Louis, the only invention of J. L. Petit's which found 
favor in the eyes of his enemies; and yet Louis, who himself calls it 
excellent, has to regret that it is far too much neglected in practice. 
It afterwards went more and more out of use, and at present it is 
almost forgotten. 

This machine was plainly a combination of the box and the sling; 
while the box of James Rae, described by B. Bell, is in reality a sling. 
Boxes had been almost discarded in the treatment of fractures, until 
Forster reintroduced them for those of the leg, with an entirely 
original addition ; and lastly, M. Baudens has recently made them , 
the basis of his apparatus for all fractures of the lower extremity, 
and even for those of the forearm. 

The peculiarity of Forster's apparatus lies in the use of wet sand, 
to fill the box and confine the limb. Besides the side-pieces and 
foot-board, the box should be closed above by another board to keep 
the sand in, having a semicircular opening to receive the ham. 
The box being half filled with the wet sand, the limb is placed in it, 
and then a suflicient quantity of sand is added to cover it to the 
level of the spine of the tibia, leaving the anterior surface of the leg 
open to view; the sand should be kept constantly moist.* 

The boxes proposed by M. Baudens closely resemble* the ordi- 
nary ones described by J. L. Petit, except that the bottom alone is 
covered with a hair pillow; the sides are each pierced with two 
parallel rows of holes, intended to allow the bands or loops for 
maintaining coaptation to pass out and be fastened on the outside. 
The foot-piece is likewise bored with holes for the passage of the 
extending loops; we shall speak again of these in connection with 
the special means used for this purpose.f 

Cushions also are of ancient origin; Galen relates that some sur- 
geons of his time, in place of a trough or box, merely laid the leg 
upon a cushion; bands arranged across this were knotted above the 
limb, so as to make all firm ; and they thought that the limb could 
be thus supported steadily enough for the patient to be removed 
from one place to another. After Galen's time we must come down 

* A. L. Richter has represented in his Atlas Forster's box, and also a modifi- 
cation of it by Kluge. See also, by the same author, Abhandlungen aus dem 
Gebiete der Praktischen Med. wad Chirurgie, Berlin, 1832 ; and an extract 
from it, given by me in the Gaz. Medicale, 1833, p. 285. 

f Gazette des Hopitaux, from Aug. 22d to Oct. 29th, 1844. 



100 A TREATISE OX FRACTURES. 

to that of J. De Vigo, to see a fracture with an external wound 
treated by merely placing it on a bed of cotton and cloth, support- 
\a at the sides only by two round pieces of wood, and fasten- 
ing it to the limb by transverse bands. But this was an exceptional 
while Pott made it a general rule to use cushions for retaining 
the limb in position. He however added the eighteen-tailed band- 
age, and splints in case of need. But we find, not long before our 
own time, Richerand and Dupuytren returning to the exclusive use of 
cushions, and treating fractures of the cervix femoris in this way; 
Dupuytren applying it even to fractures of the clavicle and cervix 
humeri. 

Slings date no further back than the eighteenth century, and 
J. L. Petit's box may be considered as the first one tried. Perhaps 
the "strap-bed" devised by Ravaton for suspending his buskin, first 
suggested the idea of a sling made of separate girths, so as to make 
a kind of hanging bed for the leg. Posch published at Vienna, in 
1774, a description of such a sling; some years later, B. Bell de- 
scribed another very similar to this, due to James Rae of Edinburgh. 
[nently, about the year 1800, Faust reproduced the flat-bot- 
tomed sling of J. L. Petit, but lengthened it for the purpose of sus- 
pension ; and again Tober adopted the separate girths, but extended 
them so as to make them a substitute for the flat bottom. "We should 
remark that thus far the sling had been used only for fractures of the 
leg; I know of no one before Delpech who thought of constructing a 
double inclined plane for the thigh, made of frames with separate 
girths stretched tightly across them. The bottom, then, may be in 
one or in several pieces, tense or lax ; and here are at once four 
great divisions of slings, varying again according as they are made 
of leather straps, of girths, of ticking, etc. I have seen one with the 
bottom knit in one piece, said to have the advantage of better adapt- 
ing itself to the shape of the limb; the name of its inventor has 
escaped me. 

But the suspensory method has called forth other forms of slings. 
Those of Posch and of James Rae, modeled on the bed of Ravaton, 
had for their basis a board of sufficient length and breadth, placed flat 
on the patient's bed. From the four angles of this board rose four 
uprights, connected at a suitable height by four cross-pieces; and to 
the two longitudinal cross-pieces were attached the straps or girths, 
by buckles or stitches. But about 1791, Lbffler having conceived 
the idea of a suspended platform, Braun combined with it the sling 
made of separate girths; his apparatus, of which I have amodel, was 
made of a board suspended by strings at the four corners; to this 
board was attached the sling, so as to hang beneath it. Faust 
applied the same mode of suspension to the simple sling; Tober 
attached the four cords to the four angles of a frame upon which 
the girths were stretched; lastly, Graefe adapted suspension to the 



A TREATISE ON FRACTURES. 191 

old apparatus of Posch. As for the rings, balances, pulleys, and 
gallows-frames, used to support the whole concern, I shall doubtless 
be excused for omitting their description.* 

Boards {planchettes) are still more modern than slings. We have 
seen that J. L. Petit and Duverney placed boards beneath their 
cushions, as supplementary to the ordinary apparatus. Pott was 
still more bold in recommending, in some cases of fractured femur, 
the putting under the cushion instead of under the thigh a very wide 
splint, differing from the ordinary board only in being hollowed out. 
B. Bell substituted a board like this for James Rae's sling, for frac- 
tures of the leg; Lbffler, going further, conceived the idea of sus- 
pending this board by four cords. By this means fractures of the 
leg may be treated by semiflexion, without the necessity of Pott's 
lateral decubitus. We want the same advantage for treating frac- 
tures of the thigh; we obtain it by using the double inclined plane. 
Thus, boards, inclined planes, suspension, all would seem complete; 
what more is needed? It remained to apply suspension to the in- 
clined plane, and to adapt the suspended boards to fractures of the 
upper extremity; to counteract lateral displacements by means of 
handkerchiefs attached to the edges of the board; these objects were 
attained by Sauter of Constance, besides whom we must mention 
M. Mayor as having essentially simplified all these apparatuses. f 

Setting aside these complications, there are still in use at present 
two great varieties of the planch ette ; the simple, and the suspended. 
To the simple board there pertain two very different modes of 
employment. 

M. Jobert, for fractures of the lower extremity, contents himself 
with the large board proposed by J. L. Petit. He places under the 
mattress a board the size of the bed. No pillow is allowed, but a 
slender bolster supports the head, so that the entire trunk lies hori- 
zontally. The limb is placed on a cushion of oat-bran, which is of 
oblong shape, and pressed down in the middle by the surgeon ; this 
cushion reaches from the heel to the thigh for fractures of the leg, 
and as far as the buttocks for those of the thigh. The limb is thus 
supported posteriorly and at the sides. A cloth, folded into a cravat 
and fastened to each side of the bed, passes across so as to prevent 

* Posch, Beschreibung einer neuen sehr bequemen Mascliine, das Fussbett 
genannt, etc., Wien, 1774; Metzler, Beschreibung der Br aun' sell en Mascliine, 
etc.. Ulm, 1800. I give these two principal references after A. L. Richter ; for the 
other German surgeons quoted in the text, see his work and atlas. The double 
inclined plane of Delpech has been described and figured by M. Gerdy, Trait6 
des Bandages, second ed., p. 408. 

t Loffler, Betirage zur Arzneiwissenschaft und Wundarzneikunst, Leipzig 
und Altona, 1791 ; Sauter, Anweisung die Beinbruclie der Gliedmassen, der 
vorziiglich die complieirten und den SchenJcelbeinhalsbruch, etc., Constanz, 
1812. (I quote these two authors after A. L. Richter.) 



192 A TREATISE ON FRACTURES. 

any anterior displacement. To this, when necessary, can be added 
continuous extension.* 

M. Mayor's system, so far as confined to simple hyponarthecia, 
- more Duverney's use of the board. This is in fact here en- 
tirely isolated from the bed. It should exceed by at least six or 
eight centimetres the normal length of the fractured limb, and by 
sixteen or eighteen its normal breadth. It is covered by a cushion 
of at least equal size, thick enough to prevent all painful pressure 
on the limb, and for this purpose stuffed with cotton, oat-bran, wool, 
tow. hay, straw, leaves, etc. This cushion we adapt to the shape of 
the limb, by hollowing it to correspond to the prominences, and thick- 
ening it by accumulating the stuffing where the parts are thin or need 
to be better supported ; so as, in a word, to make a trough exactly 
fitting the posterior third of the limb. It is best, then, that the 
cushion should have a thickness of not less than from eight to thir- 
teen centimetres, according to the nature of the stuffing and the size 
of the limb. To fix the limb, it generally suffices to pass around it 
at about the middle a very broad cravat, going also round the board, 
fastening them together and making them, as it were, one piece. If 
this does not answer, permanent extension may be made by means 
of two cravats placed round the extremities of the limb. If there 
still remains some lateral displacement, a cravat should be passed 
beneath the limb, and its ends both brought to the same side, so as 
to make the body of the cravat press on the projecting fragment and 
bring it into proper position. The two ends should be knotted at the 
other side of the board, to rings, holes, pegs, or nails, etc. How- 
ever, after having long extolled the simplicity of this method, M. 
Mayor at last owns that it is quite inconvenient and cumbersome, and 
takes a long time to get it in place. But, he hastens to add, all is 
dimple and easy, if in place of a board we make use of a ivire trough. 
Lastly, in fractures of the leg and of the thigh, it is important to 
have at the lower end of the apparatus an upright like a ladder, for 
attaching the cravat which goes round the foot, and for sustaining 
the weight of the bedclothes. 

Such is the simple hyponarthecia, which is still preferred by 
M. Gerdy for fractures of the leg.f But M. Mayor combines it in 
all cases with suspension. For this purpose he uses two cords, one 
of which, passing through four holes at the four corners of the board, 
or being fastened in some way to the four angles of the wire trough, 
should Form two loops either laterally or crosswise; these loops being 
fixed to the other cord, which hangs vertically from the ceiling or 
from a frame over the bed. But here there occurs at once a serious 
difficulty. To cover up the limb so suspended, it is necessary that 

UN mode partic. de traitement des fractures ; Bull, de TMrapeu- 
tique, May, L842. 

t Gerdy, Traits des bandages, second ed., p. 424. 



A TREATISE ON FRACTURES. 193 

one edge of the sheet and other clothes should pass up to the vertical 
cord, and then be so disposed in folds as to fall over the whole appa- 
ratus ; forming a sort of scaffolding, to be held together by means 
of pins. But however warm the air may be, neither leg can be well 
covered ; and if the mass of covering be increased, the apparatus is 
rendered less movable. M. Mayor obviates this by putting upon 
the apparatus a small down-pillow or a piece of flannel, and covering 
it up something like a doll's bed. 

Another difficulty is to know where to attach the vertical cord, 
when the bed has no frame above, or where the ceiling is too high ; 
M. Mayor advises putting two uprights, one at the head and the 
other at the foot of the bed, with a cross-piece between them, and 
then attaching the cord to the gallows thus formed. To fix the cord 
in the loops, the simplest plan is this : we place at some distance 
(about sixty centimetres) from one end of the cord a buckle or ring, 
suitable for making a running noose. We now pass the end of the 
cord through the two loops, and through the ring or buckle above ; 
and having hoisted the apparatus to the proper height, as by a pulley, 
we fasten the cord by a simple double knot, (the ordinary carter s or 
packer s knot.) 

The double inclined pla,7ie, which is strictly nothing more than a 
combination of two boards, was of later invention. It appears that 
"White, of Manchester, first conceived the idea ; but he had a ma- 
chine made of iron, adapted to the shape of the limb, and conse- 
quently too heavy and too complicated. James constructed one of 
wood, but hampered with sides so as to make its application still in- 
convenient. Sir A. Cooper, in 1798, separated the sides from the rest 
of the apparatus, so as to apply them or not, according to circum- 
stances.* I shall merely mention the double inclined planes of Sir 
C. Bell, of Sauter, and of Delpech ; describing that of Sir A. 
Cooper, my own, and lastly that of M. Mayor. 

Cooper's double inclined plane is composed, first, of a wooden 
frame reaching from the tuber ischii to the heel. At the upper end 
of this frame is jointed to it the femoral plane, which itself is hinged 
to that for the leg ; the lower end of the latter rests in a set of 
notches in the frame first mentioned, so that according to the notch 
used the flexion may be increased or lessened. Lastly, there is a 
foot-board running in a mortise cut in the leg-piece, so that it may 
always be placed in contact with the foot, whatever may be the length 
of the limb. 

* Surgical Works of A. Cooper and B. Travers, translated into French by 
Bertrand, tome ii, p. 170. note. This note is not in the original treatise by 
Cooper. It should be added that the description which follows above is founded 
on the plate given by that author ; according to the text, the lower frame is re- 
placed by aboard, and the hook by holes in which a peg is inserted so as to sup- 
port the board on which the leg rests. 

13 



[94 A TREATISE ON FRACTURES. 

I myself make use of two boards hinged together, with a foot- 
piece at the end of the plane for the leg; each side of these two 
hoards presents a raised edge, so as to prevent any slipping of the 
cushions. To maintain the degree of flexion required, there is only 
necessary a Btrap or a strong band passing from one plane to the 
Other. Lastly, when the weight of the pelvis tilts the apparatus 
inward, my remedy is to nail beneath the plane for the leg a trans- 
verse bar, which insures the firmness and proper position of the 
whole. 

M. Mayor's apparatus does not differ from the rest except in its 
greater width. It is intended to receive both lower limbs, fastening 
them together so that the sound one may serve as a kind of inner 
splint, and the sound foot afford a sure and easy means of fixing that 
of the injured side. 

Singularly enough, and not less so from the number of analogous 
facts in the history of our art, M. Mayor, while announcing in 1841 
what he doubtless considered as the last step toward perfection, found 
himself anticipated long before by the invention of fracture-beds. 

Fracture-beds are to semiflexion what large cuirasses are to exten- 
sion — a means of fixing the trunk ; and it is perhaps not without 
interest to note that while the latter are of French origin, the former 
are due to English surgeons. Harrold appears to have first con- 
ceived the idea ; Earle made some improvements on it ; and lastly 
came Amesbury. 

Amesbury's bed consists of a horizontal frame supporting three 
pieces of wood, or planes, hinged together, and long enough when 
connected for an adult to lie stretched out upon them. The upper 
plane, receiving the trunk, is naturally raised at the bolster-end; the 
middle one, intended for the thighs, is made of two pieces sliding on 
one another so as to suit limbs of different lengths, and forms with 
the third piece a double inclined plane ; this last, which supports the 
legs, has a foot-piece, used to confine the feet when this is necessary, 
and always serving to sustain the weight of the bedclothes. The 
upper of these planes is supplied with a thick mattress ; the two 
otlnrs, with similar ones only half as thick. The middle one has an 
opening with a basin fitted to it to receive the foecal evacuations ; and 
the pelvis is fixed by means of a belt passing across the upper of the 
three planes. Lastly, the hinges are movable, so that the different 
ancles may be changed at will. 

Now on inquiring into the value of hyponarthecic apparatuses, we 
see that their chief object is to maintain the position of the limb. 
Troughs form a solid plane of support, affording besides a certain 
degree of resistance to lateral displacement. Boxes, by means of 
their stuffing, are converted really into troughs; cushions are like- 
hanged, by being pressed down in the middle; slings, when 
hanging loose, are the same; slings when stretched firmly require 



A TREATISE ON FRACTURES. 195 

cushions, still hollowed into troughs ; the same is true of boards, of 
double inclined planes, and lastly of fracture-beds. Whether the 
sides are more or less raised, or more or less solid, is of small import- 
ance; or rather if the sides are too high, as in boxes, they are 
really mischievous, by preventing the careful watching and arrange- 
ment of the limb. Suppose for instance a fracture of the thigh; 
lateral angular displacement is mainly induced by the pelvis slipping 
down on the sound side ; now no one will say that the inner border 
of a trough, as deep as we usually suppose it to be, would make any 
firm resistance to this tendency. Even cuirasses do not completely 
suffice for this unless they surround the trunk and both limbs. 
Hippocrates himself brought the pretended advantages of troughs 
down to their proper estimate. "As to the question," says he, 
"whether or not a trough should be placed under the leg, it seems 
to me to be as yet undecided. They are doubtless useful, but not so 
much so as is thought. They do not hold the leg motionless, as some 
suppose; for when the rest of the body is turned to one side or the 
other, they do not hinder the leg from following the movement, 
unless the patient himself guards against it ; nor do they any more 
prevent the leg from moving to one side or the other without the 
rest of the body. They are however of real use when the patient 
has his bed changed, or goes to stool." 

If troughs give so imperfect an assurance against lateral angular 
displacements, do they not at least obviate angular displacements 
upward or downward? One would at first think so, since the limb 
rests on a solid plane. But this solid plane must be covered by a 
thick cushion; this cushion by and by gets out of shape, becoming 
thick here and thin there ; and if the heel for instance sinks too low, 
the leg will make an angle forward at the seat of fracture. The 
thicker the cushion, the greater the risk of such an event ; in other 
words, the limb is separated so much further by the padding from 
the solid plane, and the whole apparatus has so much the less solidity. 
We should therefore avoid having the cushions too thick ; and as on 
the other hand if they are too thin they allow of too much pressure, 
we see the necessity of not trusting too much to the apparatus, but 
of constantly and carefully watching it. 

Such being the case, every apparatus composed merely of cushions 
should be regarded with suspicion, and I would say the same of slings 
of all kinds. Slings made in one piece, whether loose or stretched, 
yield at last to the weight of the limb; those made in different pieces 
answer no indication, and seem invented only to increase the risk of 
displacement. The most ingenious of all these is undoubtedly that 
of Braun, who varies the height of each piece so as to fix exactly to 
the prominences of the calf and heel, and to the intermediate 
depression ; but I think no prudent surgeon would commit a fracture 
of the leg to a support so movable. 



196 A TREATISE ON FRACTURES. 

inst displacements taking place laterally, the inefficiency of 
mere troughs is confessed hy their warmest partisans. Hence Sau- 
ter ami Mayor protend to counteract them by means of their trans- 
verse cravats; and M. Bautlcns, with his bandages, merely follows 
them. But we may ask, do these cravats or bandages fulfil their 
object ? This may be doubted when we consider how liable lin'en 
band- are to relaxation; and if the muscles act powerfully against 
their pressure, not only is the displacement not prevented, but I have 
soon excoriations and sloughs ensue. 

What now is the value of suspension as applied to boards, troughs, 
etc. ? Is it merely a source of relief to the patients, making their 
confinement to bed less irksome? or is it really, as M. Mayor thinks, 
an additional safeguard against displacement? This question merits 
serious attention; but it will be more suitably discussed when we 
come to inquire what motions may be permitted to the patient. 

(6.) Of Apparatuses for Permanent Extension. — The forms of ap- 
paratus hitherto described, by maintaining the direction or pressing 
on the circumference of the limb, counteract more or less any angu- 
lar, transverse or rotary displacement ; but they avail very little if 
at all against obstinate overlapping, such as exists in oblique or mul- 
tiple fractures ; hence the necessity for permanent extension. 

This necessity has been felt since the earliest times ; thus Hippo- 
crates describes an apparatus for fractures of the leg, and Galen 
another for those of the thigh. But it is especially since the middle 
of the eighteenth century that these apparatuses have multiplied so 
fast that the mere enumeration of them would be tiresome. But 
almost infinitely various as are their forms, they range themselves 
under three classes, according as they act by traction, by distension, 
or on the principle of the lever. 

In the first, traction is made on the limb by means of loops, 
weights, windlasses, screws, or jacks. 

The simplest plan for making permanent extension is to hold the 
limb by two loops, one fastened above to the head of the bed, the 
other below to its foot. I find no mention of this prior to the begin- 
ning of the eighteenth century; but then it had come into general 
Thus J. L. Petit, for counter-extension, passed a large table- 
cloth or a half sheet between the thighs, first on the sound side, and 
afterwards, to change the point of pressure, on the injured side. 
Two other loops were arranged, one above the knee, and the other 
above the malleoli, so as to be drawn upon alternately, and thus 
moderate the pain. This method is preferred even now by Yelpeau, 
except that he puts the lower loop below the malleoli. 

However, simple as this seems to be, it is not suited to all kinds 
Of beds, and it obliges the patient to remain constantly in exactly 
the Mime place. Desault and Sauter therefore conceived the idea of 
fastening the loops to an apparatus independent of the bed, Desault 



A TREATISE OX FRACTURES. 197 

to a splint, Sauter to a board, (plancliette.) The splint of Desault, 
simplified by his successors, was to be very strong, long enough to 
reach from the iliac crest to eleven centimetres [nearly four inches] 
beyond the foot; at each end it had a mortise and a notch. The 
counter- extending loop passed through the mortise, and was tied at 
the upper notch; the extending loop was similarly attached below. 
Sauter attached his loops either to rings fixed at the two ends of his 
board, or, in the lower limb, to a sort of foot-board which served at 
the same time to keep the foot in proper position. I tried to apply 
this mode of making extension to the thigh placed in semiflexion; 
and for this purpose I added to the board for the thigh two solid 
lateral uprights, thirty-two centimetres [about eleven inches] beyond 
the knee, each of them having at its free end an opening by which 
to fasten the two ends of the extending loops; but my attempt was 
unsuccessful. 

An inconvenience common to all loops of linen, bandages, table- 
cloths, or cravats, is that they very readily stretch; it has been 
attempted to remedy this in two ways : first by substituting cords or 
leather straps; and afterwards, the knots still proving insecure, and 
the surgeon's hands not always being capable of making sufficient 
traction, recourse has been had to more powerful and more certain 
means. 

Guy de Chauliac made extension by means of a leaden weight, 
attached to the foot by a cord passing over a pulley; M. Seutin sus- 
pends a weight of five or six kilogrammes to the extending loop, and 
an equal weight to that for counter-extension. Dr. Nathan Smith 
also used a weight to make extension on the thigh, semiflexed and 
placed in its trough ; the cord was carried up over a bar fixed high 
enough to make it draw in the line of the axis of the femur. 

The windlass is more powerful than the weight, and its use is of 
greater antiquity. Gralen describes a very ingenious glossocomum, 
in which the counter-extending loops, passing over pulleys above and 
on each side of the box, came down to be coiled with the extending 
loops on a windlass placed below the whole. The windlass may be 
fitted to the foot of the bed, as by Coutavoz, or to any frame of 
sufficient solidity. J. L. Petit adapted a vertical windlass to his ex- 
tension splint.* Schmidt applied the principle to the trough, simple 
or suspended ; Posch to his sling ; and Koppenstetter to the double 
inclined plane, even putting a windlass on each division of it. 

Next to the windlass comes the screw, which may be applied in 
the same way, that is by a solid cross-piece at the lower end of any 
apparatus whatever; Boyer even made it work at the end of a long 
splint nearly similar to Desault's. [The screw is extensively used 

* Thillaye, TraiU dea bandages, p. 258. J. L. Petit himself lias written 
nothing concerning this apparatus. 



198 A TREATISE ON FRACTURES. 

in different forms in the United States. Dr. T. H. Bache, of Phila- 
delphia, lias ingeniously adapted it to the long splint for fracture of 
the thigh, bo that it may be graduated to the size of the apparatus 
employed. It is of great value in making steady and controllable 
traction.] Under the same head comes the jack,* of which I really 
know but one adaptation, that of Bellocq. 

The plan of distension does away with loops and cords; we make 
splints which keep the limb stretched either by their own elas- 
t it-it v, or by means of a screw. In the first of all known appliances 
for fracture of the leg, Hippocrates fastened two circular leather 
pads, one below the knee, and one above the ankle; each of these 
pads had on each side two pouches; into these pouches were thrust 
the ends of four rods of dogwood, which were bent in order to insert 
them, and which in straightening out tended to elongate the limb. 
Paracelsus replaced the leather pads by iron bands, stuffed, and with 
boxes for screws at the sides; for the dogwood-sticks he substituted 
steel rods, passing through the boxes and keeping the iron bands at 
the proper distance apart; then by screws, playing on the rods, this 
distance could be at will increased or diminished, and with it the 
elongation of the limb. We find something similar in the mechanical 
splint of Fabricius Hildanus, and in the contrivances of Gooch and 
Aitken, as figured by B. Bell. 

Lastly, in the system of leverage, we make use of the joint below 
the fracture to obtain a lever of the first order, and separate the 
lower from the upper fragment. The double inclined plane espe- 
cially acts in this way in fractures of the thigh; it is only needful 
for the femoral plane to go a little beyond the articulation of the 
knee ; then in flexing the leg down to the board intended for it, the 
tibia becomes a lever of the first order, the fulcrum being at the 
upper end of this board ; and the lower fragment of the femur is 
thus drawn up the plane. In fractures of the clavicle, Desault's pad 
answers as a fulcrum on which the humerus plays as a lever, to carry 
the external fragment outward. 

Such are the means hitherto used to counteract muscular action and 
restore the limb to its proper length; and at first sight it would seem 
as though nothing more could be desired. But the very power of 
these means gives rise to other dangers ; for, first of all, both for ex- 
tension and counter-extension, we must have a double grasp of the 
limb, which causes pressure or constriction in proportion to the re- 
sisting force of the muscles. Thus for example, loops passed over 
the perineum, or fastened below the knee and above the malleoli, 
bear very hard on the skin, and rarely fail to cause acute pain, exco- 
riations, blisters, or even sloughs. Again, even at such a cost, we 

■ \\ Bpeciee of hoisting machine, commonly used for raising blocks of stone, 
and having a ratchet, an iron wheel, a crank, etc—Did. de I'Academie.] 



A TREATISE OX FRACTURES. 199 

are not always certain of success. For instance, in the lower ex- 
tremity, a band passed in the fold of the groin would have too oblique 
a direction to hold the pelvis properly; and the extending loop in 
some forms of apparatus, as in that of Desault, would exercise also 
an oblique traction, which might give rise to some deviation in the 
fragments, and which at all events would make additional force 
necessary. It has been a desideratum, therefore, to overcome these 
difficulties, and diminish these dangers. Thus, for counter-extension, 
Fabricius Hildanus applied against the perineum the thick and 
rounded border of his splint. Arnauld attained the same end by 
having in the middle of the bed a post wrapped in linen ; in Bellocq's 
machine there was an analogous point d'appui; and in the cuirass of 
M. Bonnet also, the perineum is pressed upon by the upper ends of 
the two troughs for the two limbs. Nicolai went further; while 
making counter-extension by means of two loops passed beneath the 
perineum, he added a splint for extension on the sound side, and 
made both splints reach to the armpits like crutches. Tober went 
further still; besides the two crutch-like splints in the axillae, he had 
another made, of a similar shape, to press in the same way against 
the perineum.* 

Others, confining themselves to loops or to padded straps, attach 
them to a girdle surrounding the pelvis and thighs, and having at 
each side a pocket to receive the end of the extension splint. In 
J. L. Petit's apparatus, as described by Thillaye, this girdle was of 
leather, and stuffed ; in that of Pieropan, it was of iron, and shaped 
like a truss ;f Desault used a simple folded napkin to afford a point 
oVappui to the splint. I shall say nothing of those who dispense 
with counter-extension, expecting the weight of the body to offer a 
sufficient resistance; I myself had this idea when I first employed 
the double inclined plane, but experience soon led me to aban- 
don it. 

The need of direct traction by the extending loops has likewise 
led to various inventions. I shall simply mention the very compli- 
cated machine of Bellocq, which, after all, consisted merely in two 
lateral splints connected below by a cross-piece, upon which worked 
a jack. Boyer attained the same end by adjusting a foot-piece at 
right angles to his mechanical splint. Marcellin Baumers, again, 
conceived the idea of putting within the outer splint another, to 
reach not quite up to the level of the groin, to be connected with 
the inside splint by an oblique loop, and to have no other object than 
that of supporting the cross-piece below.J 

As to the means of protecting the integuments from excessive 

* See Richter's Atlas, tab. xiv and xix. 
f Thillaye, Traite des Bandages, p. 261. 

X Marcellin Baumers, 3Um. sur le bandage de Desault, etc. ; Journal G6n6ral 
de Jledecine, 1805, tome xxiv, p. 29. 



200 A TREATISE ON FRACTURES. 

pressure by the extending loops, the list of these also is very long. 
The parts pressed on have been covered with cotton; pads, cushions, 
Btnffed bands, have been used; Pieropan, unless I arn mistaken, first 
OOnceived of the laced gaiter, of which a thousand modifications 
have been made. Nothing has answered the purpose. From expe- 
riments made a good while ago, I concluded that rabbit-skin, the 
hair being turned inward, preserves the integuments better than 
anything else; and that the danger of sloughing is also notably 
diminished by fastening the loops upon plates of zinc or of paste- 
board applied over the padding. 

It has been thought that the sort of bed furnished by the immov- 
able apparatus, by distributing the pressure over wide surfaces, 
lessened its inconvenience. Thus M. Seutin modifies his apparatus 
as follows, for fractures of the femur which require permanent ex- 
tension. 

He applies over the first layer of dressing a strip of bandage of 
the width of two fingers, and retains it in place by a starched roller; 
the middle portion of this strip forms a loop below the sole of the 
foot ; its ends reach to a little above the condyles of the femur, 
where the extension should take hold, and are then folded back on 
themselves. To vary the point at which the extension shall act, a 
second loop is made a little higher up than the first, but fastened in 
the same manner. But as these loops cannot be made use of until 
the apparatus is completely dry, the extension previous to that is 
made by a loop fixed above the malleoli and made tense by a weight 
of five or six kilogrammes [twelve or fifteen pounds ;] a cloth passed 
around in the fold of the groin, carried up to the head of the bed, 
and then fixed by an equal weight, makes the counter-extension 
during the whole of the treatment. 

M. Baudens, without adopting the immovable apparatus for the 
fracture itself, borrows from it this means of making extension. 
He envelopes the leg in a layer of wadding from the feet up to the 
knee, protecting especially the instep, the malleoli, and the condyles 
of the femur. Then he puts on a few turns round the foot, loosely; 
then arranges at each side of the sole of the foot, parallel to the 
axis of the leg, the loop or middle portion of a bandage about one 
metre in length, fixing both by new turns around the foot. Now 
passing up to the knee with a very close spiral, he covers up the 
cotton and both these strips of bandage ; arrived at the level of the 
upper edge of the patella, he places on each side of the knee an- 
other doubled strip of bandage, the loop of it being downward like 
those at the sole of the foot. These are fastened by several circu- 
lar turns, after which their ends are doubled down, and fixed thus 
by several fresh turns. In this way we make two lateral loops at 
the foot, and two at the knee, through which to pass the cords for 
making extension. But as the roller will very soon become loosened, 



A TREATISE ON FRACTURES. 201 

it should be entirely covered with a thick solution of gum, (three 
parts of gum to one of water,) in order to make it firm. 

Lastly, M. Yelpeau thought that the immovable apparatus, once 
solidified, would of itself suffice for maintaining permanent exten- 
sion ; he therefore commences this extension, as has been said, by 
means of loops attached at the head and foot of the bed, removing 
them when the apparatus becomes dry. 

From the material now passed in review, it would be easy to make 
up all the varieties of apparatus for permanent extension which I 
have thought it unnecessary to mention.* A more serious question 
is whether any of them fulfil all the indications, and which of them 
affords the greatest advantages and the least inconvenience in prac- 
tice. It is necessary that the forces used should act as nearly as 
possible in the direction of the fractured bone; that the extension 
should be made as gradually, and yet as powerfully and steadily, as 
may be required; and lastly, that the pressure exerted on the limb 
should be so gentle and so diffused, as not to cause excoriations and 
sloughing. Any apparatus which will carry out these indications 
may be used to advantage ; I unfortunately know of none which 
will always answer when we have to deal with powerful muscles. 
Boyer adds a final condition, viz., that the apparatus must not press 
upon the muscles which pass over the fracture, and the stretching of 
which is necessary, thus excluding the whole system of distension. 
It is by no means proved that mere compression is of so much im- 
portance; the reason why these forms of apparatus have so nearly 
gone out of use, is rather because they are more complex than many 
others without being more efficient. It would be much more dan- 
gerous to press on the belly of a muscle so as to bend it over the 
loop, as for example if the perineal band should slip outside of the 
tuber ischii, and tend to push outward and upward the adductor 
muscles of the thigh; this should be scrupulously guarded against. 
There are, moreover, two great indications, apart from the apparatus 
used, in regard to lessening muscular resistance : the first is to relax 
the muscles by position ; the second, to soothe their irritability be- 
fore attempting to stretch them. This -last question will be treated 
of in the ensuing section. 

§ VI. — Of the Choice of Apparatus. 

After so extended an exposition, which is yet very far from com- 
plete, of so many forms of apparatus, each supported by good 
authority, we may readily understand that the surgeon is at once 
met by the difficulty of making a proper choice. We say, first of 

* The reader might consult on this point, besides the authors already quoted, 
two Theses of the Concours for fellowships in the Faculte of Paris ; the first 
by 1L Robert, 1832 ; the other by M. H. Larrey, 1835. 



202 A TREATISE ON FRACTURES. 

all, that tliis; almost infinite diversity of means to one and the same 
end, la perfectly explained by two general facts, viz.: that some 
fractures are so simple, that they may be perfectly cured by any 
method, and with any apparatus; and that others are so obstinate 
as to Bet at defiance more or less all the means at our command; so 
that, by not properly discriminating between different cases, each 
inventor of a new system has always been led to extol his own suc- 
cess, and to contrast it with the failure of others. 

Should a fracture occur without displacement, the bone being kept 
in position by the one collateral to it, as in cases of serrated fracture 
of the tibia or fibula, bandages, splints, immovable apparatuses, hy- 
ponarthecic apparatuses, slings, or even simple cushions, any of these 
will succeed, any of them will be suitable, the simplest or the most 
complicated ; the only rule for the surgeon to observe is to discard 
whatever is plainly useless. In a word, there is here only the most 
elementary indication for treating all solutions of continuity : to keep 
tJie parts immovable. 

But if there is a displacement which tends to recur, a new indica- 
tion presents itself: to preserve, as much as possible, the exact rela- 
tion of the fragments. And this general indication divides itself 
into as many different ones as there are varieties of displacements. 
Angular displacement is generally overcome with ease ; but mere 
cushions, or slings, do not afford sufficient support for the weight of 
the limb ; a posterior plane is required, horizontal or inclined ; and 
sometimes lateral pressure by splints, troughs, or boxes. Rotary 
displacement calls for something more ; in fractures of the lower ex- 
tremity, for instance, the foot must be kept up by means of an upright, 
or by a regular foot-piece. Transverse displacements are still more 
stubborn; we have to act on the projecting ends of the bone with im- 
mediate splints, or with the lateral cravats of Sauter and of Mayor; 
the former seem to me far superior to the others, although even they 
are not always sufficient. I say nothing of displacement by separation, 
which demands the use of special apparatus; and lastly, when there is 
obstinate overlapping, our only resource is permanent extension. The 
immovable apparatuses, if suitably supported during the period re- 
quired for their drying, are very efficient against angular and rotary 
displacements, except when they become too large from the shrink- 
ing of the limb ; but they are worthless against displacements in the 
thickness of the limb, and yet more so, in spite of the assertion of 
M. Velpeau, as a substitute for permanent extension. 

So far, we have only considered the condition of the bones ; but 
we must recollect that we act only on the bones through the thick- 
ness of the soft parts. The danger of firm and prolonged pressure 
in making permanent extension is known to every one ; but though 
less in other forms of apparatus, it is quite as real. Thus circular 
constriction, a little too strongly made, may bring on oedema, without 



A TREATISE ON FRACTURES. 203 

causing excoriations ; local pressure, especially over subcutaneous 
bony prominences, as the malleoli, heel, etc., may give rise to pain, 
and sometimes to sloughing ; lastly, the limb, kept too long immova- 
ble, will be subject to articular stiffenings not easily remedied. Doubt- 
less this all depends very often quite as much on the surgeon's negli- 
gence as on the apparatus employed ; the best apparatus, if badly 
managed, may do harm, just as the worst may have its defects -com- 
pensated by the skill with which it is used. But it is no less true 
that much depends in this respect on the apparatus ; thus I have 
before said that, in using the plaster, or any immovable apparatus, 
it is a wise precaution to cover the skin first with a layer of dry band- 
age, and to pad with wadding or with agaric the points most subject 
to pressure. As to stiffening, and even anchylosis, it has been esta- 
blished that they more frequently ensue from extension than from 
semiflexion ; but the immediate and most powerful cause is the too 
prolonged want of motion in the joints. Hence the propriety of a 
medium posture for all the articulations which must be kept at rest ; 
hence the value of occasional passive motion, and the danger of cir- 
cular bandages embracing the limb down to its extremity. The 
history of these bandages leads us to this curious result: that .until 
Boyer's time no one covered up the forearm entirely for fractures 
of the arm, and that Boyer himself abstained from doing so in the leg; 
for my own part, returning again to the old practice, I have never 
seen oedema ensue in the parts left uncovered except when the band- 
age had been too tightly drawn. On the whole, whatever apparatus 
any one may select, it must fulfil a third indication : to protect the 
member, as much as jjossible, from excoriation, sloughing, oedema, 
and anchylosis ; I will add a fourth, less important, to be sure, in 
simple than in compound fractures, but never to be neglected unless 
for some particular reason : the apparatus should leave the limb suf- 
ficiently exposed to allow of any symptoms which may arise being 
seen at once. 

Lastly, besides the requirements of the fracture itself, the state 
of the patient should sometimes influence us in our choice of appa- 
ratus. Very young children will soil with urine any dressing placed 
on the thigh; we need for them, therefore, something easily and 
cheaply renewed ; and it is well to cover any such application with 
waxed cloth, so as to keep it dry as long as possible. Insane or 
delirious patients need firmer means of restraint; for instance, 
M. Mayor, having an insane patient who would not keep her bed, 
could devise no better plan than to surround the limb with cotton and 
with compresses, so as to give it a nearly cylindrical form, and then to 
confine it by the two halves of a tin pipe, like a high boot ; so that 
the patient could even walk without very great danger. The use of 
the strait-jacket would keep the most restless subject in bed ; and 
the plaster-apparatus would answer the same end as M. Mayor's me- 



204 A TREATISE ON FRACTURES. 

tallic boot Bat it is very rarely that we need such powerful means. 
I have found it a good plan, in a case of fracture of the leg where I 
had reason to fear the restlessness of the patient, to arrange the 
limb on a wide cushion, doubled up at the sides and supported by 
pong Bplints, so as at once to confine the limb and leave its 
anterior surface exposed. Among the insane at Bicetre, I used also 
lateral splints without any previous bandaging, having placed the 
whole limb on a double inclined plane, so as to fix the thigh and foot 
as well as the leg. 

On the whole, in exceptional cases as well as in ordinary practice, 
the >urgeon who becomes a partisan of any one apparatus exclu- 
sively, deprives himself, in my opinion, of valuable resources, and 
lavs himself very much open to the charge of empiricism. As I 
have before said, the indications are the end, the apparatus merely 
the means. The indications always remain the same ; the means 
may vary greatly. Hence, then, in the treatment of fractures as in 
all other therapeutics, the choice of apparatus is but of secondary 
importance ; the great thing is to appreciate the indications. 

§ VJLL — Of the proper Time for applying the Apparatus. 

First of all, it is important to establish an essential distinction 
between such apparatuses as merely serve to insure the proper posi- 
tion of the limb, as cushions, inclined planes, slings, etc., which vary 
according to circumstances, and must always be applied at once, and 
such as are intended to maintain the reduction, enveloping the limb 
more or less, and exerting compression or extension. 

The question, so circumscribed, touches in many points that con- 
cerning the most favorable time for accomplishing the reduction ; and 
it has received quite as various solutions. Hippocrates, in cases of 
fracture in the long bones, applied at first a compressory bandage, 
renewed every two days, waiting till from the seventh to the eleventh 
day before putting on the splints. This practice prevailed through- 
out the good old times ; and we must come down to Paulus iEgineta 
before we find the moderns, as he calls them, putting on the perma- 
nent apparatus at once. The latter was still the practice of surgeons 
in the time of Rhazes, who criticises it severely. It succeeds, says 
he, when there is neither wound nor inflammatory action ; but more 
commonly the premature compression brings on unfavorable symp- 
toms. In spite of this authority, most of the Arabian school, with 
Hagues de Lucques at their head, adopted the immediate application. 
The sixteenth century again put in force the Hippocratic plan, but 
it lost favor once more in the eighteenth. Lastly, among the sur- 
geons of our time who have adhered to the compressory apparatus, 
some, with Boyer, apply it from the very first day, but with the pre- 
caution of putting it on lightly, and removing it on the following 



A TREATISE OX FRACTURES. 205 

day ; others, like Larrey and M. Velpeau, put it on at once for the 
entire period of treatment. 

Each plan has some reasons in its favor. From not taking off the 
apparatus on the second day, says Boyer, the limb has been seen to 
mortify, the bandage becoming too tight by reason of the spelling 
of all the parts and impeding the circulation ; and at this first re- 
moval, we generally find the limb swollen, tense, hard and painful. 
According to M. Yelpeau, on the contrary, far from augmenting the 
pain, the apparatus soothes it ; if there is only the swelling caused 
by sero-sanguineous extravasation, compression prevents the develop- 
ment of inflammation; if this latter already exists, compression will 
favor its resolution. 

It would be hard to understand how such experienced observers 
could so differ in their results, if one did not remember, first, that 
there are some fractures for which one or the other practice may be 
followed indifferently; and again, that even in such as, being accom- 
panied by swelling and inflammation, appear especially to demand 
the greatest care, compression has sometimes had the happiest re- 
sults. But this cannot shut our eyes to its dangers, which M. Vel- 
peau himself admits in a passage too remarkable not to be quoted: 
"Although compression, rightly made, constitutes a really heroic 
practice, I should warn you also that when employed unskilfully it 
may become the cause of more or less serious symptoms. Do not 
forget it ; it is a valuable resource in surgery ; but let me say this, 
it allows of no half-way." 

In truth, other partisans of the immovable apparatus have made 
it one of their precepts not to draw the bandage too tight, and 
M. Laugier claims it as a merit of his paper apparatus that it does 
not exert pressure. But it is much less the active pressure exerted at 
the moment by the bandage which is injurious, than the secondary 
and in a manner passive pressure caused by the swelling of the limb. 
Apart from this, what could be milder than the ordinary compresses 
and bandages, which always become relaxed in less than twenty-four 
hours? And yet one cannot deny that these apparatuses, prema- 
turely applied, have given rise to serious symptoms; there is no hos- 
pital where such instances have not been observed; and 3}upuytren, 
alarmed at their frequency, established a general rule that every 
patient affected with fracture should be visited twelve hours after the 
apparatus was put on, and that this should be reapplied at the first 
indication of any excessive pressure.* 

The immovable apparatus, of whatever kind, is no more exempt 
from this, than the rest. In a young girl with double fracture of the 
humerus, M. P. Meynier had applied the albuminated dressing; next 
day there appeared yellowish phlyctense and a livid color of the skin 

* Cltmque de Dupuytren; Gaz. MMtcale, 1832, p. 853. ^m 



'Jut'i A TREATISE ON FRACTURES. 

about the elbow; the apparatus was quickly removed, but so severe 
were the symptoms for several days, that the surgeon greatly feared 
tike necessity of amputating the arm at the shoulder. M. Defer has 
Been gangrene ensue from the premature application of the starched 
bandage For a fracture of the humerus and for one of the patella; 
M. Blandin has seen fatal results from the same cause. And even 
when there was no danger of gangrene, we haye all seen, in one of 
the most distinguished of our Russian brethren, Professor Doubo- 
vitzki, the sad effects of a starched bandage applied immediately after 
a fracture of the elbow. When the apparatus was renewed, on the 
twenty-fifth day, the flexors of the wrist and fingers were indurated, 
blended into a hard cartilaginoid mass with the surrounding cellular 
tissue; it was impossible to raise up a fold of the skin over them; 
the wrist and fingers were entirely paralysed. This induration gave 
place to obstinate retraction, for which the patient submitted to 
twenty-nine subcutaneous sections; with what result is well known.* 

Moreover, no one denies these facts ; only the partisans of the im- 
movable apparatus declare that they are to be attributed to the band- 
age being badly applied. M. Velpeau is more liberal, acknowledging 
that even if it be well put on, it does not entirely do away, with the 
danger; but "it is easy," he adds, "by carefully watching the com- 
ing on of the symptoms, examining the color of the skin, noting the 
appearance of phlyctense, etc., to know rightly when the apparatus 
should be removed." But besides that the immovable apparatus, ex- 
tended over the whole length of the limb, leaves only the ends of the 
fingers or toes in sight, I fear that this so-called guarantee would 
only engage practitioners in a false security. I have particularly 
studied the manner in which gangrene comes on in cases of fracture ; 
and often I have seen it developed locally, without pain, or any other 
notice either to the surgeon or his patient. M. Velpeau himself has 
reported a very remarkable instance of such an insidious onset of 
gangrene; one of his patients, in whom such symptoms were de- 
veloped, nevertheless assured him that he felt very well, and thus 
gave him a confidence sadly disappointed by the result. 

Thus then, rarely enough, but much to be dreaded, and often im- 
possible tp suspect beneath the bandages, gangrene may follow the 
immediate application of constricting apparatus. Call it the fault of 
the surgeon, that point may be questioned; it is of slight importance, 
if somehow or other it is well known that your principle has its 
dangers. I can understand, however, that one would run the risk, if 
no other way were open to him, or if he had some great interest in 
so doing; but it is this very interest which is wanting; the hypo- 

* P. Meynier, Observations, etc. ; Gaz. Mtdicale, 1832, p. 61 ; Defer, 06- 
servatiom de gangrene, etc. ; Gaz. Medicate, 1839, p. 446 ; Blandin, Discuss. 
ad. de Me'decine, Aug. 6, 1839; Doubovitzki, Me'moire sur la section 
eouecutante, etc. ; Annates de la chirurgie, tome i, p. 129. 



A TREATISE ON FRACTURES. 207 

narthecic apparatus suffices to support the broken limb until all danger 
of inflammation is past; and if need be we may have recourse to 
lateral splints as I make use of them, namely, without any previous 
bandaging, and leaving a large portion of the limb exposed. 

Could we not however apply an ordinary roller, or the bandage of 
Scultetus, carefully renewing it once or twice a day, as advised by 
Boyer and Dupuytren? There is no objection to this plan, except 
first that such bandages are entirely useless, and again that they may 
do harm by the disturbance of the limb necessary for their renewal. 

I establish therefore as a general rule: 

That in no fracture ivith swelling and inflammation, should any 
compressing apparatus, surrounding the limb, be applied until all 
danger from that source has subsided. [This rule has for many 
years been observed in the Pennsylvania Hospital, and with very 
successful results. Whatever the fracture may be, if there is any 
tendency to inflammation, the latter is the first object of attention; 
and for the first few days, the limb is examined carefully at least 
once in every twenty- four hours.] 

Perhaps also it would be prudent to postpone such applications for 
some days even in the very simplest fractures, so as to allow of the 
effusion of coagulable lymph, and the development of the provisional 
tumor ; in order that there may be the least possible danger of any 
defect or delay in the consolidation. 

The question comes up still more seriously as to the apparatus for 
permanent extension. In oblique fractures of the femur, Desault 
made extension from the first day or two, and said that he effected 
cures without any shortening. Boyer on the contrary thought that 
it would cause irritation of the parts, and powerful spasmodic con- 
tractions of the muscles, if used at once ; he preferred waiting seven 
or eight days until the irritation and spasm were allayed, and even 
longer if such symptoms continued beyond that time. Lastly, Ld- 
veille, going still further, put forth the general rule that permanent 
extension should not be made till half the time required for consoli- 
dation had gone by; so that if the case required sixty days, he 
would wait until the thirtieth. 

An important point to establish in solving this question, is that 
permanent extension, in oblique or multiple fractures, is permanent 
reduction; and hence amenable still more strictly to the laws of 
ordinary reduction. If we are called immediately after the accident, 
so that the fracture may be reduced without the employment of 
great force, we may hope to retain it also without danger; at least 
it will be safe to attempt it. But if the next day the muscles, con- 
tracted by inflammation, obstinately resist our efforts, it would be 
highly imprudent to struggle against them, whether to effect reduc- 
tion, or to maintain that already effected. Hence the rule given by 
LeVeiUe is an extreme one ; by waiting so long, we should often risk 



208 A TREATISE ON FRACTURES. 

finding the muscles confirmed in their shortening, and the callus so 
Bolidified as to oppose a new difficulty to the reduction. Boyer's 
advice is better; but he errs perhaps practically, in applying his ap- 
paratus for fracture of the thigh from the sixth to the ninth day. 
In a st.mt man, in whom I had employed permanent extension on 
the sixth day of a fracture of the thigh with about five centimetres 
overlapping, I was compelled to remove the apparatus after three 
dav-: the shortening had increased to eight centimetres. The limb 
being placed between two ordinary splints, and extension being 
Blightlv applied occasionally, I was much astonished at finding, on 
the twentieth or twenty-fifth day, a shortening of less than three 
centimetres. We see here how the forcible stretching, by irritating 
the muscles, had increased the shortening at first, and how subse- 
quently the mere allaying of the muscular irritation by rest, favored 
elongation. On the whole, the callus hardly beginning to organise 
until after one-third of the time required for its complete consolida- 
tion, I think we risk nothing by waiting thus long before applying 
permanent extension; although if the muscular irritability subsides 
earlier than this, we need not waste time; nor should we be too 
hasty if it should last longer.* 

§ VIII. — Of the Time for removing the Apparatus. 

Surgeons have hardly agreed any better on this question than on 
the last one. The practice of Hippocrates was as follows: if coap- 
tation were exact, if there were neither itching nor danger of ulcera- 
tion, he would leave the apparatus in place until consolidation was 
completed ; but if he had never so little doubt about the perfect 
position of the fragments, then, at or a little before the middle of the 
time during which the splints should remain on, he removed the 
whole apparatus, satisfied himself of the reduction being permanent, 
and reapplied the dressings as before. This method prevailed until 
the time of Paulus iEgineta; but then it fell into disuse; some, like 
Paulus himself, renewing the application more frequently; others, 
going to the opposite extreme, putting it on at the beginning, to 
take it off only at the end of the treatment. 

Of these three plans, the first has hardly been put in practice ex- 
cept by some zealous Hippocratists of the sixteenth century; the 
other two, although quite opposite to one another, have always pre- 
vailed. Even in our own time, we have seen Boyer removing his 
dressings every five or six days so as to assure himself of the exact 
state of the fracture; while Larrey, applying his immovable appa- 
ratus in its purity, put it on on the first day only to take it off on 
the last. 

gaigne, De V extension continue dans les fractures, etc. ; Gaz. Me'dicale, 
1836, p. L70. 



A TREATISE ON FRACTURES. 209 

These frequent renewals of Boyer's are really unjustifiable ; and 
he himself shows their uselessness when he advises that the bandage 
should not be removed, in all, more than three times, if a roller has 
been employed. As I have said before, if the fracture is attended with 
severe symptoms, we should leave it exposed, and not hide it beneath 
an inclosing apparatus ; if there is any danger of displacement, we 
should doubtless be advised of it, but at the proper time; when there 
is no such danger, I see no motive for deranging the apparatus 
and disturbing the position of the limb, and imitate Hippocrates in 
leaving it untouched until consolidation is complete. 

If, on the other hand, it is asked why Larrey used his immovable 
apparatus, the reason alleged is the incontestable fact, that abso- 
lute immobility is the safest guarantee of a prompt consolidation. 
If however it be objected that we must assure ourselves that the 
fragments are in place, the answer is that if they are properly re- 
duced, and the apparatus properly applied, there is no risk of their 
becoming disarranged. To those, lastly, who would suggest that with 
the swelling present for the first few days reduction might not have 
been very exact, it is replied that this is a matter for every surgeon 
to decide by his own experience. 

Such answers certainly leave to the objections all their original 
force. There is no experience, however extended we may suppose 
it to have been, which would always enable us to say that the frag- 
ments, masked by the swollen state of the soft parts, were reduced ; 
moreover it has been demonstrated that while inflammatory swelling 
exists reduction is impossible. And what shall we say of the changes 
which may take place in the state of the limb? Sometimes, the 
swelling disappearing, the fractured ends play upon one another; 
or perhaps the atrophy of the limb from inaction sufiices of itself to 
leave a space between the bandage and the skin; I say nothing of 
cases in which the displacement occurs during the time required for 
the desiccation of the immovable apparatus, as I have described the 
means for preventing this ; but it may occur, and not unfrequently 
does, at the very time of application of the dressings, when the first 
compresses and the first turns of the bandage conceal it from view. 
"What mistakes there may be then in this portion of our art, com- 
monly thought to be so far advanced! How many displacements 
may ensue, deforming the limb, if not crippling the patient, to the 
lasting reproach of the surgeon ! 

Thus, having long ago returned in this respect also to the prac- 
tice of Hippocrates, I assert that there is a positive and pressing in- 
dication to examine the fracture before consolidation is complete; 
and the time which should elapse before this examination Hippo- 
crates has stated as distinctly as possible, viz., about two-thirds of 
the period necessary for union. When we expose the limb at this 
time, if the fractured ends are found in perfect contact, the appa- 

14 



210 A TREATISE ON FRACTURES. 

ratua is replaced as before, and the surgeon may justly feel safe; 
but if there is any displacement, he is in time to remedy it. I have 
therefore established this general rule: 

In simple //•(ictures, but with a tendency to displacement, the 
apparatus should be renewed at the time when the callus, although 
fairly organised, has not yet become ossified; that is to say, after 
about two-thirds of the time required for consolidation. 

Generally we may, after this, leave the dressings undisturbed 
until the end of the treatment; but should the displacement give us 
any cause for anxiety, we should again renew them as often as may 
be thought proper; sacrificing the advantage of perfect rest to the 
no less urgent necessity, both to surgeon and patient, of avoiding 
deformity. 

I have here discussed only the question of removing the apparatus 
at stated times; should the patient complain of any itching, or of 
pain, or should the surgeon suspect any still more serious condition, 
the examination should be made at once. 

[The operation of bending the callus of a broken bone is one by 
no means free from pain, or even danger; and the longer the adja- 
cent joints are kept at rest, the greater the pain and difficulty of 
making passive motion in them. Moreover, not only is the approach 
of gangrene oftentimes extremely insidious, but the repair of a frac- 
ture is materially favored by a sound and transpirable condition of 
the skin overlying it. From these considerations it may be seen 
that the advantages attending the frequent examination and redress- 
ing of broken limbs are very great; so great, as in the opinion of 
most surgeons to counterbalance the risk of disturbing the position 
of the fragments, which after all may be obviated by using due 
caution. Constant and careful watching of the fracture from the 
outset, has saved many a patient from permanent crippling.] 

§ IX. — Of the Movements which may be allowed to the Patient. 

When the upper extremity has sustained a fracture, we may 
generally allow the patient to sit up, without any bad result; al- 
though the movement communicated to a broken humerus in the act 
of walking has more than once delayed consolidation in that bone. 
In the lower extremity, on the contrary, confinement to bed has 
generally been considered necessary ; but this is thought sufficient ; 
and provided the patient does not leave his bed, he is allowed and 
even directed to use some motion. 

Thus when he raises himself to go to stool, or to eat his meals, it 
would seem so simple a thing, that since the times of Guy de 
Chauliac it has been recommended to let a cord hang from the ceil- 
ing within reach of the patient, to aid his movements. It was only 
a few years ago that M. Bonnet of Lyons called attention to the 



A TREATISE ON FRACTURES. 211 

displacements which may ensue, and illustrated the point by experi- 
ment. 

Having sawed the femur in a dead body, obliquely downward and 
forward, so that the upper fragment overlapped the lower, "If," 
says M. Bonnet, "the neck was flexed, the upper fragment of the 
femur was not at all moved. If the thorax was gently raised, the 
upper fragment descended and passed forward a little ; but as soon 
as the flexion of the trunk became more marked, approaching to a 
right angle, the upper fragment of the femur took a direction to- 
ward the back of the thigh,' and passed downward and forward 
more than an inch toward the knee, as well as a little outward. 
These displacements disappeared gradually, as the trunk was re- 
placed in the horizontal position. If in bending the trunk the pelvis 
also was raised, the displacements were the same, but occurred to a 
greater degree." 

And M. Bonnet adds : "From these experiments one may well he 
convinced of the danger incurred in fractures of the thigh, if the 
pelvis he raised to allow of the hedpan heing passed under the 
patient."* Moreover, he obtained analogous results in regard to 
fractures of the leg. 

Such deductions are really startling; for in view of them we can 
hardly understand how a fracture of the femur can ever be consoli- 
dated. But the very extent of the result precluded full confidence 
in it ; I therefore resolved to repeat the experiments under various 
circumstances, so as to find out where they were at fault, — to de- 
termine the proper amount of injurious effect from motions of the 
trunk, — and to seek to discover some remedy. 

A body with the muscles relaxed being laid on the table, and the 
femur sawed as mentioned, I found at once that on raising the head 
and trunk, overlapping occurred to the extent of about three centi- 
metres ; but the limb being put on a double inclined plane, the over- 
lapping did not exceed one centimetre. I observed besides two very 
curious phenomena; to wit, that in restoring the body to the hori- 
zontal posture the overlapping was diminished sensibly, but was 
not, as stated by M. Bonnet, completely effaced; and again, that if 
the trunk was inclined forward, the overlapping was likewise dimin- 
ished. 

Studying this experiment attentively in all its details, it is easy 
to see that in raising the trunk at first, the pelvis was made to 
work backward and forward on the tuberosities of the ischia; the 
cotyloid cavities being thus carried forward, we have here at once a 
cause of overlapping ; but moreover, these tuberosities, meeting no 
obstacle, slipped down more or less toward the foot of the table ; a 
second cause of overlapping. When the limb was on the double 

* Bonnet, Mtm. citi, Gazette Midicale, 1839, p. 520. 



212 A TREATISE ON FRACTURES. 

inclined plane, the femoral portion somewhat prevented this sliding 
of the pelvis; the overlapping was produced almost entirely by the 
first cause; hence it was much less in degree. And we may under- 
stand likewise that in bringing the trunk again into the horizontal 
position, the effect of the sliding still remains, and therefore the 
overlapping can only partially disappear. If during the experiment 
the pelvifl was raised by an assistant, the overlapping varied accord- 
ing as he held it immovable or allowed it to yield to the weight of 
the body. Lastly, when the trunk was strongly inclined forward, 
it reacted in the opposite direction by its weight upon the ischiatic 
tuberosities, which now slid backward, drawing up the upper frag- 
ment. 

If this be so, we could obviate the last cause of overlapping, the 
sliding of the pelvis, by means of a loop passed between the but- 
tocks ; and we might expect also that the action of the other cause, 
the to-and-fro movement of the pelvis, would be notably hindered in 
this way. In fact, by making counter-extension in the manner just 
mentioned, the trunk has been raised with the limb in all positions, 
without any observable degree of overlapping. 

These results being placed beyond doubt, it nevertheless seemed to 
me that much more weight would be given them by repeating the 
experiment on the living subject and in an ordinary bed. I tried it 
first with a sound person; the two legs being equally extended, we 
should in case of overlapping see the heel, which here represents 
the upper fragment, descending. 

I began by raising the head and the chest, telling the subject to 
keep perfectly passive, making no effort whatever; the heel actually 
descended, but much less than the upper fragment had in the dead 
body; and examining into the cause of this, we found that the hol- 
low made in the mattress by the buttocks almost entirely prevented 
the slipping down of the pelvis. 

I then asked the subject to raise himself by means of the cord, 
using the hand corresponding to the limb we were observing. There 
was a movement of the heel, but it was hardly pushed downward; 
and hence there would hardly have been any overlapping. The 
overlapping was a little more marked, by using the other hand, 
or both hands together; but it was still very slight; and it be- 
came nothing when the pelvis was held fast by a counter-extending 
loop. 

Lastly, repeating these same processes with patients affected with 
ohliqne fractures of the thigh or of the leg, I have seen that all the 
movements of the trunk, and especially such as were voluntary, 
were communicated to the upper fragment, in extension as well as 
with the double inclined plane; but the overlapping was hardly sen- 
sible; and this is especially easy to observe in the leg, where any 
motion would be evident both to the sight and to the touch. 



A TREATISE ON FRACTURES. 213 

It follows from all these experiments that the danger is much 
less than stated by M. Bonnet, although still claiming serious atten- 
tion. When we have to raise the body of a patient too feeble to 
help himself, the pelvis should be prevented from descending by an 
assistant, placing one hand in the fold of each groin; or better still, 
in every fracture where there is danger of overlapping, we may fix 
the pelvis by a cloth folded cravat-wise, passed under the perineum, 
and fastened by both ends to the head of the bed. When the patient 
is robust and can raise himself, we should recommend him to use in 
preference the hand corresponding to the broken limb. We may 
also derive advantage from a precaution advised by J. L. Petit, and 
subsequently by Boyer himself. This was to fasten at the foot of 
the bed a solid and firm board, upon which was nailed a block 
covered with a cushion or a small mattress. This block is one of 
the greatest possible comforts to the patient ; it serves him to press 
against occasionally with the sound foot, so as to push himself up 
when he slides down in the bed, and to raise himself with the cord 
without fear of sliding down or overlapping. 

Other motions of the trunk may likewise have an injurious influ- 
ence ; thus, says M. Bonnet, in a fracture of the right thigh any 
bending of the body toward the left would carry the upper fragment 
outward ; any bending of it toward the right would carry it inward, 
and these displacements would be more or less marked in proportion 
to the extent of the lateral motions of the trunk. So also of rotary 
movements of the trunk ; whenever one side of the pelvis is raised, 
that of the sound side for instance, unless the two fragments are 
closely united, the upper one partakes of the motion of the pelvis ; 
the weight of the body acting in part upon it, and the pressure of 
the plane on which it lies pushing it toward the inner side of the thigh, 
it sustains a double displacement, rotary and angular. M. Bonnet 
remarks, however, that the displacement is greater if the whole pelvis 
is raised at once ; and the case is the same, or nearly so, with the 
leg. 

There is some truth in these remarks, but like the former, they are 
certainly exaggerated, Every day, indeed, we make patients with 
fractured thighs go through both lateral and rotary motions, when 
we raise the pelvis to pass the bedpan beneath them ; and yet all 
these fractures unite more or less favorably under the use of ordinary 
apparatus. This is because the splints, pressing on both fragments, 
oppose a considerable obstacle to the effect of these movements of 
the trunk ; the counter-extending loop, which hinders the pelvis from 
descending, is another safeguard quite as efficient ; and although the 
cuirass, making at once both limbs and the trunk immovable, would 
be assuredly preferable in theory, practice has shown, and still shows 
us every day, that it may very well be dispensed with. It is import- 
ant, however, that the patient should be warned to keep himself as 



214 A TREATISE ON FRACTURES. 

perfectly at rest as possible, especially during the first third or the 
first half of the time requisite for consolidation. 

While M. Bonnet advocates absolute immobility, M. Mayor finds 
on the contrary that it is carried to an excess in the ordinary forms 
of apparatus; and insists strongly on the advantages of the suspended 
board. ''Patients," says he, "as soon as they are placed on the 
suspended hyponarthecic apparatus, can execute without danger any 
movement parallel to the horizon, whatever may be the gravity and 
the complications of their fractures." And as proof of his asser- 
tion, he gives the following experiment. 

" Break both bones of the leg of a skeleton, and lay them on a 
suspended board. Put the different fragments together as in coapta- 
tion, and see if these pieces, though in no way fastened to one another, 
will be in the least deranged by the various motions which you may 
impress on the board, and if you cannot turn it in all directions 
without disturbing the bones, which here represent a comminuted 
fracture." 

This experiment cannot be really serious. That one may put thus 
on a board two isolated fragments, forming with it, according to 
M. Mayor's expression, one and the same piece, and that they will not 
move, I admit. But just attach the upper of two fragments, either 
to a fixed or immovable body like the pelvis or to a lever connected 
with the pelvis, like the femur, and you will see what changes of 
position will be induced by the lateral movements of the board ! 

Moreover, it is very different when these motions are made by an 
exterior force ; we must ascertain whether or not the movements im- 
pressed on the trunk, raising it, inclining it to the right or left, or 
the movements which it executes of itself, involve greater derange- 
ment of a limb placed on a movable board, than of one placed on a 
firm apparatus. I have made some experiments in reference to this 
point, which it may be useful to relate. 

I sawed obliquely through both bones of the leg in a dead body, 
a little above the middle, so that the upper fragment overlapped the 
lower. The leg being put upon a double inclined plane, the over- 
la}) ping was notably augmented by raising the trunk forward to an 
angle of 45°; but when the leg was on a simple suspended board, 
the overlapping hardly increased at all ; there was, however, a much 
more considerable relative movement of the fragments, by which 
they made an angle salient externally, the foot being carried inward. 

I reduced the ends so that they mutually sustained each other, and 
overlapping was impossible. Raising the trunk in the manner before 
mentioned, the leg being sometimes on the double inclined plane and 
sometimes on the simple suspended board, the derangement was 
always greater in the latter case, and always occurred in the same 
direction as in the other experiment. This unlooked-for result de- 
ma rifled an inquiry into its cause, to find which it was not very diffi- 



A TREATISE ON FRACTURES. 215 

cult. The lifting of the trunk tends to push downward the upper 
fragment ; with the fixed apparatus, this either over-rides freely the 
lower one, or merely transmits an impulse in that direction ; but with 
the suspended board, the movement impressed on the upper fragment 
is transferred first to this board, which, being longer than it is wide, 
sways to the right or left according as the ham lies nearer to one or 
the other edge, and carries with it the lower fragment. 

An exactly similar oblique section was made in the femur, and the 
limb placed sometimes on a fixed double inclined plane, sometimes on 
the same in suspension. But this time it was evident that the rais- 
ing of the trunk induced less overlapping, and therefore less motion 
in the fracture, with the suspended than with the fixed apparatus. 
It was to no purpose that I varied the experiment, making the frag- 
ments now overlap and now oppose one another, or inclining the 
trunk to the right or to the left ; the derangement was always less in 
case of suspension ; and the apparatus induced no sensible deviation 
laterally, as did the simple leg-board. 

I know, and was the first to perceive, the incompleteness of these 
experiments, and their need of clinical confirmation. Hitherto time 
and opportunity have been wanting for me to pursue these researches ; 
I believe, however, that we are able to prove at least conditionally, 
(1) that suspension lessens the danger from movements of the trunk 
in fractures of the femur ; (2) that in fractures of the leg, the simple 
suspended board has perceptible disadvantages, and should be re- 
placed by the double inclined plane. 

Some surgeons, however, have gone much further ; and led away 
by the fact that fractures in the upper extremity do not prevent pa- 
tients from getting up, have sought to extend this liberty to the 
lower extremity. Amesbury, if I am not mistaken, was the first to 
let patients walk with broken legs. In his apparatus, the leg and 
thigh were fastened by straps to a very light double inclined plane, 
and moreover confined by lateral splints. A sort of sling fixed to 
the end of the leg-piece served to suspend the weight of the limb by 
the patient's neck ; and he was thus enabled to walk on crutches 
after about the third to the eleventh day, according to the state of 
the limb ; in 1831, the author published several cases thus treated 
with very good results. In 1832, M. A. Berard, with the albumi- 
nated apparatus, allowed patients with fracture of the leg to walk 
about ; lastly, in 1836, M. Seutin extended the liberty of walking 
to all fractures of the lower extremity. 

I must confess I have never been much attracted by this plan. In 
the first place, we must consider that it is of no therapeutic value ; 
the surgeon seeks here only to please the patient, to dazzle him by 
a sort of tour de force not without some originality. When this in- 
volves no risk, we may certainly attempt it. Thus in fractures of 
the fibula, where the tibia serves as a splint and prevents displace- 



121G A TREATISE ON FRACTURES. 

ment, T Bee no objection to it; in simple fractures of the leg, after 
consolidation La somewhat advanced, we may resort to it, although 
the danger to the patient, from falls, should be seriously taken into 
account. But in recent fractures, in those especially in which the 
tendency to displacement cannot always be overcome by perfect rest, 
I regard this plan as an extremely imprudent one. Amesbury him- 
self has made an exception in regard to oblique fractures; in these 
he keeps the patients in bed till the fibula is united, which occurs, he 
says, in fifteen days or three weeks; and again, in the simpler cases, 
he urges the patients never to move the limb by its muscles, but al- 
ways passively, by means of the sling. A slight safeguard, and one 
to which few surgeons would be willing to trust ! Moreover, in spite 
of his boasted successes, this plan in fractures of the leg has never 
made many proselytes either in England or in France; and I believe 
that even M. A. Berard has abandoned it. 

As regards fractures of the femur, since the best forms of appa- 
ratus, with rest in bed, so seldom effect a cure without shortening ; 
since to the difficulties of the fracture itself are added the dangers 
of attempting to walk, without the hope of even the slightest benefit, 
such temerity happily needs no opposition ; for I know of no surgeon 
in France who would be willing to make trial of it. 



§ X. — Of the Treatment of Complicated* Fractures. 

Although the indications established for the management of simple 
fractures have an equal value as regards others, yet the latter pre- 
sent themselves under such various conditions, that our precepts 
must be sometimes modified, and always extended, to suit them. 

Thus reduction is effected by the same rules; but there may occur 
two circumstances which, increasing the difficulty and danger, involve 
new indications : first, when the fragments protrude through the in- 
teguments ; secondly, when the fracture is comminuted. 

In fractures of the thigh or leg, it is generally the upper fragment 
which thus protrudes, and only in exceptional cases the lower. The 
difficulty of reduction is in proportion to the narrowness of the 
wound and the length of bone projecting; if the wound is too small, 
we should boldly enlarge it in the direction and to the extent neces- 
sary for putting back the fragment ; if this presents a long sharp 
point, hindering reduction in spite of the enlargement of the wound, 
it must be resected before making any fresh efforts. 

Hippocrates recommended, in difficult cases, a resource which I 
am sorry to see dismissed from modern surgery ; this was the moch- 

* [Coi/q>ou/td, according to the American and English nomenclature.] 



A TREATISE ON FRACTURES. 217 

licus, a sort of iron lever, like that used by stone-cutters, widened 
and flattened toward the end. Extension being made as usual, this 
lever was slipped in between the fragments, so that its lower face 
bore upon the lower fragment, while its upper face was applied on 
the end of the upper fragment, raising it and pushing it up to the 
level of the other. 

But when we use such powerful means, and upon limbs which have 
suffered such violence, we should especially bear in mind the great 
rule, not to struggle against spasm and inflammation, but either to 
prevent them or wait till they subside. There may however occur 
here one of the greatest practical difficulties ; shall we leave the end 
of the bone sticking out, to become necrosed, with all the chances of 
inflammation and suppuration entailed by such a displacement, and of 
the moral effect on the patient ? Hippocrates has forcibly represented 
the surgeon's position : not to reduce it, says he, is to incur the re- 
proach of ignorance ; to reduce it is to increase the chances of death. 
However, he does not hesitate to prefer the patient's interest to that 
of the surgeon ; he would not reduce. This is also the opinion of 
Boyer ; if there is too much difficulty, says he, we had better wait for 
suppuration. Such cases are happily rare, and I have not for my 
own part had occasion to see them. It appears to me, however, that 
the advice of Hippocrates and of Boyer should not be followed unless 
the limb were attacked with an intense inflammation, involving the 
integuments ; otherwise, we may adopt a middle course between total 
inaction and rediiction, by bringing the projecting fragment from one 
side to the other, within the muscles, so as to restore at least the 
natural direction of the limb. I would say more : in the majority 
of fractures of the femur, for instance, when a fragment protrudes 
through the integuments, we cannot hope for complete reduction, so 
difficult even in simple fractures; and it would very often be highly 
imprudent to persist in attempting it. 

[I have already alluded (see note on page 166) to two cases of 
this kind, in which the operation of resection of the projecting ends 
was performed, with satisfactory results.] 

The fact of a fracture being comminuted does not imply much 
danger when the integuments are intact ; and even when they are 
wounded, if the wound is small, and heals by the first intention, we 
need not be alarmed at the presence or number of the splinters. But 
when suppuration is inevitable, these splinters constitute an extremely 
grave complication; they act as foreign bodies within the tissues, and 
must be extracted as soon as possible. We have already had occa- 
sion to speak of the well-known fracture of the leg sustained by 
Pare; it was compound and comminuted; so the great surgeon took 
care to advise Richard Hubert, who dressed the injury, "que si la 
playe n'estait suffisante, quil Faccreust avec vn rasoir pour remettre 



31 8 A TREATISE ON FRACTURES. 

lit&nent les os en leur position naturelle; et qiiil recherchast 
diligemment la plage auee les doigts, plustost qu'auec autre instru- 
ment [ear le sentiment du tact est plus certain que nul autre instru- 
ment pour oxter les fragments et pieces des os qui pourroient estre 
du tout eeparSee: mesmes quil exprimast et feist sortir le sang qui 
eitoit en grande abondance aux enuirons de la plage."* 

A. Part* put in practice for himself the precept which he had first 
announced for fractures by gunshot, which are par excellence com- 
minuted, and for which he recommended, in 1545, to begin by ex- 
tracting all the splinters which are separated. This rule is retained 
to our own day, but not without some important modifications. I 
have already said (see ante, p. 115) how often gunshot fractures, even 
after consolidation, become the seat of small abscesses, each from 
the separation of a splinter; and the most expert surgeons, after 
extracting with the greatest care all the detached pieces, have ob- 
served similar consecutive eliminations. Often even those splinters 
which adhere are thrown off before the consolidation is complete; A. 
Tare had this to go through with. Percy, therefore, modifying Pare"s 
rule, left only such splinters as he thought could be again united ; 
"Those," he adds, "which did not seem capable of such reunion, 
should be separated from their connections, and treated as foreign 
bodies likely to do mischief, "f But recently M. Baudens has gone 
farther, and would advise the extraction of all the movable splinters 
caused by gunshot fractures of the body of a long bone, ivhether ad- 
herent or not. The facts upon which M. Baudens relies are worth 
stating. 

An Arab had had both bones of the forearm broken by a ball. 
The free splinters were all removed ; but during eight months fresh 
discharges of them successively took place, and the patient at last 
succumbed from purulent infection. The bones were found partly 
united by a very voluminous eburnated callus, having a great many 
radiating cavities still containing movable splinters about half dis- 
charged. 

A young soldier had received a ball at about the lower third of 
the ulna; the free splinters were removed, and the adherent ones left. 
Four months afterwards, numerous splinters, successively escaping, 
kept up an active general and local irritation. M. Baudens made 
free incisions, and drew out a dozen splinters of different sizes, so as 

["That if the wound were too small, he should enlarge it with a razor, so 
as more easilyto replace the bones in their natural position; and that he should 
carefully explore the wound with his fingers, rather than with any other instru- 
ment, (the sense of touch affording the greatest certainty,) in order to remove 
Mich fragments and bits of bone as might be completely detached; pressing out 
and evacuating also the blood which was abundantly effused about the wound."] 
t I'crcy, Manuel de chir. cVarm6e, p. 193. 



A TREATISE ON FRACTURES. 219 

to leave no foreign bodies in the wound ; two months afterwards, 
consolidation and cicatrisation were both complete. 

Another had had the ulna broken an inch below the olecranon. 
The surgeon made an incision two and a half inches long, and took 
out three movable splinters, leaving two others because they adhered 
strongly to the soft parts, and especially because they entered into 
the articulation. At first everything went on well; but at different 
times there occurred swelling and heat around the fracture ; finally, 
the suppuration still continuing, a probe was introduced, detecting 
some bits of necrosed bone, which were extracted after enlarging the 
wound. These were the splinters which the surgeon had endeavored 
to save, because the tendon of the triceps was firmly adhered to 
them ; their removal was speedily followed by recovery. 

Iff. Baudens cites also several cures of fractures of the tibia, ob- 
tained in this way. He makes, however, two exceptions to the rule ; 
the first for fractures of the femur, which according to him impera- 
tively demand amputation, a view which will be hereafter discussed ; 
the second for fractures of the facial bones. Here, in fact, the vi- 
tality is so great, and the reparative process so energetic, that ad- 
herent splinters can and ought to be preserved, and extraction should 
be confined to such as are entirely detached. In the case of the 
lower jaw, however, the vitality is less, and the ordinary rule holds 
good.* 

These facts, we think, demand the serious attention of surgeons ; 
we see, moreover, that the practice of M. Baudens is not so very 
novel, since that of Percy closely resembles it. Whichever course 
we adopt, we must give our incisions the full extent necessary for 
extracting the pieces with the least possible dragging and pain, and 
such a direction as to facilitate at once the dressing, and the escape 
of pus ; and we should also avoid as much as we can opening the 
great muscular sheaths, so as not to have protrusions of the mus- 
cles. The finger, according to Pare"s precept, should be the first 
instrument carried to the bottom of the wound to detect, loosen, and 
seize the pieces ; and if it does not itself do all, it should at least 
direct our other instruments. Lastly, when by means of incisions 
we have brought the fragments, without excessive difficulty, to the 
external opening, it is well to resect any sharp points which would 
irritate the tissues and prevent proper coaptation. 

Reduction once made, we have only to maintain it, just as in simple 
fractures ; but we must carefully attend to the dressing of the 
wound. 

The wound may present itself in various conditions. It is some- 
times small, with its edges uncontused, and seemingly ready to unite 
by the first intention ; this union, making the fracture a simple one, 

* Gazette des Hopitaux, 1836, pp. 366, 379, 386, 487. 



■2'20 A TREATISE ON FRACTURES. 

should be the point aimed at by the surgeon. To obtain it, it gene- 
rally Bufficea to cover the wound with a little diachylon or lead-plas- 
terj but one essential precaution is to protect this part from all 
pressure, and even to leave it exposed, under our continual inspec- 
tion. J. Hunter occasionally substituted for the plaster a bit of 
charpie dipped in the blood; a practice imitated by Sir A. Cooper, 
and highly lauded by Amesbury. I have several times found this 
plan useful, hut have succeeded quite as well with the plaster; and 
Hunter himself recommends one or the other indifferently. 

The ease is not so plain when the wound is large, irregular, cut in 
flaps, with edges more or less bruised. Hugues de Lucques first 
united these wounds by suture, embracing the skin and adipose tissue, 
but avoiding the muscles, and leaving the whole untouched for ten ( 
days afterwards. Theodoric, who has preserved to us this plan, says 
that he has tried others, but none so successfully ; Guillaume de Sa- 
lieet and Guy de Chauliac adopted it after him, and were imitated 
by Fabricius d'Acquapendente and Wiseman ; only this last author 
established a distinction between ordinary compound fractures, with- 
out very great contusion of the skin, and gunshot fractures, in which 
the suture could not be used. In our times it is pretty generally 
abandoned, and in the classical treatises it is not even mentioned. 
Such neglect seems to me by no means justifiable, and in the fol- 
lowing case I had reason to congratulate myself on having employed 
the suture. 

A carpenter, fifty years of age, was using a jack to raise an enor- 
mous mass of wood; the jack slipping, the beam fell on the inner 
side of his right leg, tore the integuments into a flap for an extent 
of three and a half inches, stripping them from the tibia for one inch, 
and broke both bones at the lower part of the wound, about six 
inches from the ankle-joint. Notwithstanding the attrition of the 
skin, I attempted to obtain union by means of five points of the 
twisted suture, and one of the interrupted. The pins were withdrawn 
on the fourth day, and union seemed to have taken place, when some 
days afterwards a slight inflammation was set up around the wound, 
separating its edges, and giving exit to some pus. But the union at 
the bottom of the wound was firm, protecting the fracture from the 
air; and at the end of two months consolidation was complete. 

Here the advantage was very great, and cheaply obtained. Sup- 
pose, indeed, that the suture had failed; things would only have been 
reduced to their original condition, without any more danger to the 
patient. I think then that in such a case the suture affords an in- 
valuable resource, if used with judgment. 

When lastly the wound is not of a nature to unite either by means 
of plaster or the suture, we must expect a tedious suppuration, at- 
tended also with danger; and the necessity of combining attention 



A TREATISE ON FRACTURES. 221 

to such a wound with the treatment of the fracture has given rise to 
a good many plans and forms of apparatus. We shall study these 
last in the same order as those for simple fractures. 

We have already said that for certain fractures attended with 
wounds, Hippocrates had recourse to the many-tailed bandage, ap- 
plying first the strip which should cover the wound ; he insisted first 
of all on the wound being covered ; but another school cotemporary 
with him conceived of enveloping in bandages and compresses the 
rest of the limb, leaving the wound exposed, so that it might be con- 
veniently dressed without deranging everything. As to the splints, 
Galen recommended putting them on each side of the wound, so as 
to avoid pressing too much upon it. 

This system of leaving an opening in the bandage was retained in 
Upper Asia in spite of the opposition of the greatest masters ; Rhazes 
found it in full force, and tried in vain to overthrow it; and we see 
it finally adopted by Avicenna and Albucasis. Avicenna arranged 
his bandage so as to leave the wound free, and even made a corre- 
sponding opening in the splint ; Albucasis appears to have been the 
first who thought of applying the bandage in the ordinary way, and 
afterwards cutting out with scissors a hole of the required size. 
Afterwards, J. L. Petit, going back to the many-tailed bandage, ap- 
plied it in the opposite mode to that of Hippocrates, keeping the last 
strips to cover the wound, in order to be able to replace them, when 
soiled, without deranging the others or disturbing the limb. All the 
modifications attempted since are included under those we have men- 
tioned, until the change I have introduced in apparatuses of this 
kind, which consists in applying the splints and their padding merely, 
without any bandage whatever. 

All the apparatuses with splints are constructed with the idea that 
it is necessary to dress the wound frequently; only sometimes the 
dressing requires a complete removal, sometimes only a partial one, 
and at other times is accomplished without any disarrangement what- 
ever. The albuminated apparatuses of the middle ages were at first 
made with an opening opposite the wound; Hugues de Lucques and 
Theodoric alone applied a complete bandage, which they renewed at 
first not before the tenth day, but afterwards every seven or eight 
days. Larrey, in our own day, went further ; he applied his appa- 
ratus just as for simple fractures, and removed it only when union 
was complete. It was of no account, in this method, if the suppura- 
tion was abundant ; the pus flowed out between the dressing and the 
limb, and was merely wiped away; if it soaked the bandage so as to 
lessen its solidity, new compresses were applied on the outside. 
Maggots even might be engendered beneath the apparatus; this was, 
according to Larrey, an advantage, since they ate away the dead 
parts, and hastened the cleansing of the wound; and he only renewed 
the dressing if they became too numerous, their number only being the 



222 A TREATISE ON FRACTURES. 

BOurce of trouble. This plan, however, has not been generally 
thought prudent, and M. Seutin cuts his starch-bandage after the 
manner of Albucasis, while M. Velpeau applies his dextrine appa- 
ratus so as to leave the wound exposed, as did the ancients, and as 
did Avicenna, 

When the plaster-dressing is used, an opening is likewise left op- 
posite the wound ; and thus, as we have seen, the Arabian bonesetter 
proceeded, the account of whose treatment is given us by Eaton. 

In the same way, when cuirasses are used, they are furnished with 
an opening for the examination and dressing of the wound, and I 
need add no more to what has been already said. 

Troughs, boxes, cushions, slings, boards, and all the forms of 
hyponarthecic apparatus, may be applied almost without modification 
to the treatment of compound fractures, since they leave exposed so 
large a portion of the limb. If the wound is at the posterior part, 
we may make openings in the box or trough, leave out one piece 
from the sling, replace the board by an open frame; I shall merely 
allude to the apparatus of Gray, consisting of three trough-like por- 
tions, supported by three uprights placed at suitable intervals ; one 
portion was fitted to the knee, another sustained the leg, and the 
third was provided with a foot-board, to keep the foot in place.* 

Lastlv, apparatuses for making permanent extension are still more 
convenient for dressing the wound, since they keep the limb fixed 
without entirely concealing any part of its circumference; and it 
was for compound fractures that Hippocrates conceived the appa- 
ratus for distension, before spoken of. 

In fine, these forms of apparatus present three varieties : the first 
comprises those in which the apparatus must be wholly or in part 
removed at each dressing of the wound, thus involving inevitably 
some motion in the limb ; the second those in which the wound is 
dressed the first day and then left to itself; and the third those in 
whieli the dressing of the wound and the immobility of the limb are 
at one and the same time provided for. 

Of these three plans, the first, comprehending all applications of 
rollers or bandages sustained by splints, from the apparatus of Hip- 
pocrates to that of Boyer, should be absolutely rejected; the neces- 
sary movements of the limb, besides retarding consolidation, directly 
inducing inflammation and suppuration. The second, in spite of 
some brilliant successes, is subject likewise to too much inconvenience 
and danger. The first annoyance, which is certainly one of the 
least, lb the fetid exhalation sometimes taking place from the appa- 
ratus. I have seen at Val-de-Grace a mere extravasation of blood 
between the compresses, which compelled us by its odor to change 

* Tlic London Med. and Plxys. Journal, Sept., 1825. Richter has also given 
a representation of this apparatus. 



A TREATISE ON FRACTURES. 223 

the entire dressing of a fractured leg. Another very palpable incon- 
venience is the loss of solidity of the bandage, when the suppuration 
is copious enough to soak through the whole thickness of the com- 
presses. When things reach this point, the pus flows between the 
skin and the dressings ; one portion stagnates in the interspace due 
to the emaciation of the limb, while the rest flows continually toward 
the heel, giving out a horrible smell. 

All this would however be still trifling. But unhappily we have 
too much reason to fear that the pus will burrow between the integu- 
ments and the muscles, and between the muscles and the bone, en- 
dangering the limb and even the life of the patient. I have else- 
where published the case of an old soldier, a stout, sanguine man, 
who fell from a ladder, and sustained a compound fracture of the 
tibia at its lower part. The immovable apparatus was employed ; on 
the eighteenth day it had to be removed on account of the insup- 
portable fetor. Four days later, pus flowed abundantly by the heel. 
On the tweDty-ninth day, the increased discharge and the excessive 
fetor made a fresh removal necessary; the whole leg was pasty and 
flaccid; there was no trace of callus; a probe, introduced by the 
wound, passed up several inches between the two bones; the tibia 
was denuded at its external face ; sinuses were formed in the limb 
above and below. Several surgeons regarded amputation as una- 
voidable. This however was postponed, and by great care, after 
three incisions had been made, and a long train of severe symptoms 
had been overcome, a satisfactory cure was effected by the end of six 
months.* 

It avails little for the partisans of the plan to call this case an 
exception; no prudent surgeon would expose a patient to such un- 
pleasant exceptions. 

There remains the third plan ; and this may be divided at once 
into two great methods, according as we either inclose the limb in a 
complete envelope, open only opposite the seat of the fracture, or 
leave the limb exposed. 

The former mode of proceeding has been strongly criticised by Hip- 
pocrates himself. The wound, alone remaining free in the midst of 
compression, soon swells and assumes an unfavorable aspect; its 
edges become everted; serum is discharged instead of pus; the pa- 
tient experiences febrile heat and throbbing; and Hippocrates con- 
cludes by saying: u I would not have so much dwelt on this method, 
had I not fully known its dangers, and of what importance it was 
to warn practitioners from adopting it." 

Some of these symptoms doubtless arise from the apparatus being 
put on before the inflammation has subsided; and it is certain that 
they do not so constantly supervene as Hippocrates would seem to 

* Lancette Francaise, June 17, 1830. 



224 A TREATISE ON FRACTURES. 

teach. But the danger has struck several of the modern partisans 
o\' the plan, and not merely as regards swelling of the wound; for 
by hiding the parts around, we also cover up from view any abscesses 
or sinuses which may form in the vicinity. The following case, 
which I take from the Clinique of M. Velpeau, will show plainly 
enongh what we have to fear. 

A compound fracture of the leg was sustained by a man thirty- 
eight years of age; a dextrine bandage, open opposite the wound, 
was applied. On the sixteenth day, there was found by means of a 
probe a fistula extending about two inches downward from the wound. 
The apparatus was renewed, leaving both wound and fistula exposed. 
The twenty-first day, there was fever, and an abscess had formed 
between the wound and the fistula; this abscess was opened, and by 
this opening the end of the upper fragment was felt to be bare. 
Some days after, there were symptoms of purulent infection, and 
death ensued on the twenty-ninth day. 

I am certainly far from pretending that any apparatus whatever 
would always afford security against similar accidents ; but I would 
have the surgeon on his guard, and I would have such dressings used 
as would permit him to keep a careful watch over the whole surface 
of the limb, to recognise the symptoms and to combat them at once. 
Strange! physicians, having to deal with organs they cannot see, 
exhaust their art to explore them, to sound the depths of the visceral 
cavities; to read through the thickness of their walls, to translate as 
it were the malady to the exterior ; while we surgeons, having before 
our eyes abscesses, diffused inflammation, sinuses, wounds, seek to 
hide all this with our bandages, and to deprive ourselves of what I 
would call our ante-mortem autopsy. 

I therefore discard the immovable apparatus, and the plaster ap- 
paratus, which is more dangerous because it exerts more compression ; 
or at least, I would not resort to it until long after all danger of in- 
flammation, or of the formation of sinuses, had passed away. Even 
cuirasses are unsafe, because they also conceal too much. We are 
not however without available means. 

If the wound is trifling, and the displacement little or nothing, we 
have at hand the entire hyponarthecic apparatus, cushions, troughs, 
hoard-, etc. For greater security, after having laid the limb on a 
board or a double inclined plane, I add at the sides junk-bags and 
splints, without bandages or compresses; oedema is best prevented 
by giving the limb a raised position. The wound, when it cannot be 
closed, is dressed with a simple bit of lint, covered only by a light 
compress. The simplicity of this treatment is evident; nor need we 
concern ourselves to settle the question how often the limb is to be 
re-dressed, as we must when other plans are adopted. In practice, 
having the wound and the parts around it, always in view, I leave 



A TREATISE ON FRACTURES. 225 

the lint in place as long as no change occurs; as soon as any new 
condition arises, inflammation, suppuration, or what not, I am ready- 
to meet it. If the wound is at one side, I put a splint only on the 
opposite side, retaining it in place by two cravats, by a dextrine band- 
age, or better still, by two wide strips of lead-plaster. If the wound 
is beneath, and the limb cannot be so placed as to leave it at one 
side, one cushion should be arranged above it, and another below, so 
as to guard against any pressure upon it; or we may replace the 
board by an open frame, or by a special apparatus like Rae's box. 

When the fragments are considerably overlapped, burying their 
sharp points in the tissues, we must resort to permanent extension. 
But in comminuted fractures, when we have had to remove a good 
many splinters, or to resect the end of one fragment, or when, from 
whatever cause, the fragments are obstinately separated from one 
another, lateral compression, which even under other circumstances 
is not always reliable, cannot be safely applied to the parts sur- 
rounding an irritable wound; and here is a real deficiency. In these 
difficult cases, recourse has been had to ligature or suture of the bone. 

The first mention of the ligature dates back to the last century. 
Icart, surgeon of the Hotel-Dieu at Castres, says he saw it used with 
success by Lapujade and Sicre, surgeons of Toulouse; and he himself 
defends it against the attacks of Pujol.* The plan consisted in em- 
bracing the fragments with a tightly-drawn wire of brass, silver or 
lead, to be left in place until the fragments no longer needed it to 
hold them together. I know of no one who has used the ligature 
since then except M. Baudens; he applied it in a compound fracture 
of the jaw. 

The suture is much more modern ; attempted at first, after resec- 
tion, as we shall see further, it was applied in 1838 by M. Flaubert 
of Rouen, in a compound fracture of the humerus from crushing by 
a wagon-wheel. The extraction of a very large splinter had left the 
two fragments, slender and very sharp, approaching one another only 
by their points. The suture was applied just as after resection; un- 
happily, about the eighth or tenth day, the lower fragment became 
necrosed; and the thread, which had cut through the upper frag- 
ment after three or four weeks, came away with the necrosed portion 
of the lower at the end of six weeks. Union had however begun, 
and although delayed by all these untoward circumstances, was 
completed firmly in a few months. f 

These are undoubtedly extreme resources, and should only be 
adopted in extreme cases. Sometimes necessity gives great value to 
means which we may commonly despise. M. Warmer has related 

* Pujol, Memoire sur une amputation, etc. ; Icart, Lettre en rtyonse ati 
Mem. de M. Pujol ; Pujol, Eclaircissements en re'ponse, etc. ; Journal de M6- 
decine, 1775, tome xliii, p. 160, xliv, p. 164, and xlv, p. 167. 

t Laloy, De la suture des os, etc., These inaug., Paris, 1839. 

15 



226 A TREATISE ON FRACTURES. 

the case of a Mahometan priest who was shot in the upper part of 
the thigh. Three Arabian apparatuses (djebira) were successively 
applied without any benefit ; the priest buried his limb in sand, which 
absorbed the pus; and at the end of a year of perseverance, the 
femur had united with a shortening of eleven centimetres, [nearly 
four inches,] so as however to allow of his mounting a horse, and 
even travelling some distance on foot.* 

I si uill conclude this section with an important practical remark. 
The danger lasts until the wound is closed, or at least lined by a 
.solid pyogenic membrane, and shut off from communication with the 
fracture. After this the treatment becomes much simplified, since 
we have only to watch the consolidation; and any apparatus, immov- 
able or otherwise, may be conveniently applied. 

§ XI. — Of the Treatment of Symiotoms. 

After the reduction, and the application of the dressings, there 
remains to be performed by no means the least important duty of 
the surgeon ; he must use all care to ward off unfavorable symptoms, 
and to remedy them when they come on. 

A fracture which is simple from the first, or which becomes so during 
the treatment, demands only that the patient should have a regimen 
sufficiently generous to afford materials for consolidation. This re- 
gimen should be first of all substantial and abundant. Fabricius 
Hildanus has remarked that the use of gelatinous food retards con 
solidation; and I have before mentioned several cases in which in- 
sufficient diet had plainly exerted such an influence. Hence in all cases 
of fracture, I hasten to bring the patients back to their usual food, 
from the first day if there is no inflammation, or at any rate as soon 
as the inflammation has subsided. Boyer advises one or two bleedings 
in fractures of the lower extremity, even when simple, keeping the 
patient on broth for the first few days, then allowing soup, and later 
gradually bringing him to more solid food; lastly, he prescribes some 
soothing and refreshing drink. In spite of so high an authority, in 
fact on account of the weight it carries with it, we must say plainly 
that this course is not founded in reason. We may bleed, if it be 
indicated, and prescribe diet and tisanes if they are indicated; but 
if the pulse is calm and the appetite good, dieting and bleeding are, 
to say the least, useless. 

Another much abused means is the application of topical remedies 
to the broken limb. Hippocrates smeared it with cerate; Hugues 
de Lucqucs rubbed it with a bacon-rind, and afterwards covered it 
with honey. Duverney used compresses soaked in camphorated 

* Warmer, Du trait, des plates d'armes d feu chez les Arabes Bedouins de 
VAlgSrie, These inang., Montpellier, 1839. 



A TREATISE ON FRACTURES. 227 

brandy or with lead-water; Larrey, fomentations with camphorated 
vinegar, etc. All this is mere empiricism, without any object, or 
any plausible reason. There is no objection except its uselessness 
to the application of a moist compress; but fatty or oily inunctions 
irritate the skin, cause eruptions and very uncomfortable itching, 
and sometimes even bring on erysipelas. Fomentations, continued 
during several days, induce a sodden state of the limb, and hence it 
is better not to employ them. 

But there may occur in the course of the treatment various local 
and general symptoms, several of which might well be called com- 
plications, if custom had not limited this word as before mentioned. 

The local accidents may be 'primitive or consecutive. Among the 
former we place contusions, excoriations, phlyctense, extravasations 
of blood, primitive false aneurism, muscular spasm and inflammation. 

(1.) Contusion may be slight or serious, limited or extensive; it 
is sometimes accompanied by ecchymosis spreading widely among 
the cellular tissue. To whatever degree it occurs, even if it is severe 
enough to make us dread gangrene of the integuments, we can do 
nothing to dispel it. The majority of surgeons resort in such cases 
to topical remedies called resolvents, which we shall soon have again 
to mention ; I myself long followed this practice. Dissatisfied with 
its results, I sought to find something more reliable; and in exten- 
sive ecchymoses, for instance, I frequently tried fomenting one por- 
tion with camphorated brandy, with lead-water, etc., leaving the 
rest exposed to the air merely; resolution occurred as readily in the 
one as in the other. The only really important indication is to ward 
off subsequent inflammation; for this we should resort to bleeding 
and low diet ; and the best of all topical applications are emollient 
cataplasms. But if there is no sign of inflammation, it is best to 
leave the work to time and nature, taking care only to guard the 
contused part from undue pressure. 

(2.) Excoriations, or even open wounds, not communicating with 
the seat of fracture, should be treated in the simplest manner, and 
as if no fracture existed; all pressure on them should be avoided. 

(3.) Phlyctence resulting from the violence of the contusion are 
unimportant, and should be carefully distinguished from such as 
precede or accompany gangrene. Boyer recommends opening them, 
leaving the epidermis undetached, and putting on a rag smeared with 
cerate. This plan is not troublesome, and is not without its advan- 
tages when we want to apply a circular bandage to the limb ; but if 
we leave the part exposed to the air, we may content ourselves with 
emptying only the largest vesicles by puncture, leaving the rest to 
absorption. 

(4.) Bloody effusions occur under two different forms. Some- 
times we have an infiltration of the limb, greatly augmenting its 
volume, but nowhere presenting any fluctuation; if we can keep 



228 A TREATISE ON FRACTURES. 

down inflammation, resolution almost always occurs. Boyer cites a 
remarkable case of this. A bleacher broke his leg by falling from 
a wagon. Three or four days afterwards, the limb swelled enor- 
mously, and the skin became purple and mottled. It was thought 
that the anterior tibial artery had been injured; nevertheless, the 
infiltration making no progress, nothing was done but to bleed, and 
to apply emollient cataplasms locally. Under this treatment the ten- 
sion rapidly diminished, and the engorgement passed away, leaving 
however a large ecchymosis, which gradually disappeared. 

Another and more serious form, is when there is a large effusion be- 
neath the skin, fluctuating, and raising the integuments like those 
over an abscess. In such cases Bromfield did not hesitate to make 
free openings, and Larrey adopted the same practice. Undoubtedly 
a slight complication is thus disposed of, but only at the risk of a 
greater, — at the least a suppurating wound, and in the majority of 
cases a direct communication between the fracture and the atmos- 
phere. Hence most surgeons prefer leaving such collections to nature. 
They generally end in absorption; but it is very important that no 
pressure whatever should be exerted on the skin, tense as it is, lest 
a slough should be induced; and the safest plan according to my 
experience is to leave the part open to the air, without any sort of 
application, unless inflammation should come on and change the 
aspect of things. If however absorption should not occur, we can 
at any convenient time make an opening, perhaps after the fracture 
is united. I have but once seen a collection of this kind resist 
absorption, without the occurrence of suppuration ; the case may be 
briefly given as follows. 

A coachman, thirty-eight years old, had his leg broken at the 
upper part by a carriage- wheel passing over it; a vast collection of 
blood distended the integuments, which seemed very much thinned; 
fluctuation was very perceptible, and the least movement gave rise 
to a good deal of crepitation. When he was admitted into the hos- 
pital, the resident physician covered the limb with a compress soaked 
in lead-water, and placed it on a cushion, supporting it by two lateral 
splints. Next day I had him bled to four bowlfuls, [sixteen ounces; 
each palette or bowl containing four.] On the third day there 
was a good deal of swelling and redness of the integuments; he 
was bled to three bowlfuls; emollient cataplasms were applied, 
and continued until the twenty-second day. The effused blood was 
in great part absorbed; there remained, however, a spot of fluctua- 
tion which threatened to open, for the skin became very thin and 
assumed a violaceous hue. On the forty-first day I concluded to 
evacuate it by puncture ; there flowed out from forty to fifty grammes 
of a reddish-brown, thick liquid, like chocolate, without any coagula, 
but with some few small masses of fat. The microscope discovered 
no pus-globules in it. Suppuration was now speedily set up in the 



A TREATISE ON FRACTURES. 229 

cavity, and I had to make free incisions. Still, the consolidation 
was quite advanced, and the abscess acted like a simple one; it 
closed in less than three weeks, and on the eighty-third day after 
the fracture the patient walked about on crutches. 

The premature opening of this collection, introducing the exter- 
nal air to the seat of a comminuted fracture, would assuredly have 
greatly delayed the cure, to say nothing of the danger to which it 
would have exposed the patient. 

(5.) Primitive false aneurism is nothing more than an effusion of 
blood, caused and kept up by a wound of an artery. The difference 
then between this and ordinary extravasation from veins or capil- 
laries is, that this effusion tends to increase rather than to diminish, 
pulsations are perceptible in it, and the necessity of checking it is 
urgent. 

A case of this kind is related by J. L. Petit. In a fracture of 
the leg, the anterior tibial artery had been wounded ; the limb was 
ecchymosed, became cold and livid, and was believed to be gangre- 
nous ; Petit made an incision three fingers'-breadths long, laid bare 
the artery, and arrested the bleeding; the fracture united in the 
usual time. 

In spite of this remarkable success, Pelletan amputated the thigh 
in three cases of fracture of the leg with effusion of arterial blood, 
and lost two of his patients.* Boyer, without any personal ex- 
perience on the point, thought that we should cut down upon the 
artery, and tie it above and below the point of injury. Lastly, in 
1809, Dupuytren employed successfully the ligature by Anel's 
method, f and advised it for all cases of this kind. 

In a case of fracture of the leg at the inferior third, on the second 
day there were pulsatile movements in the calf, perceptible both by 
the sight and by the touch, isochronous with the pulse elsewhere, and 
immediately arrested by pressure on the femoral artery. Dupuytren 
ligated this vessel at the middle of the thigh ; the tumor gradually 
disappeared, and the patient recovered simultaneously from the effu- 
sion, the operation, and the fracture. 

In 1815, Delpech had a similar case, with a similar result ; and 
so also had subsequently Mr. B. Cooper, in a patient with an injury 
of the popliteal artery by fracture of the femur. 

Such is therefore the plan to be pursued in preference to that at- 
tempted by J. L. Petit or that advised by Boyer. But although 
effusions of this kind ordinarily occur almost at the same time as the 
fracture, there are cases in which they do not show themselves until 
much later. In one observed by Pelletan, the extravasation did not 

* Dupuytren, Des anevrismes qui compliquent les fractures ; Logons Orales, 
second edition, tome ii, p. 507. 

t [The same as that of Hunter, viz., at some distance above the affected 
part.J 



280 A TREATISE ON FRACTURES. 

appear till after the thirtieth day, the only precursory phenomena 
having been pains in the calf, coming on at about the fifteenth; 
after the amputation, dissection of the leg showed a rupture of the 
peroneal artery. When the aneurism has been so long in developing 
itself, should we not dread its being maintained from the distal por- 
tion of the vessel, and prefer ligating above and below the seat of 
injury ? The history of these arterial effusions shows indeed that 
Anels method is not certain, in such cases; and it may be added that 
after thirty days the fracture would be so far advanced toward union 
that we need have very little fear of our incision doing harm by lay- 
ing it open to the air. 

There remain, lastly, wounds of arteries complicating fractures 
which are already compound, and hence bleeding externally. Is the 
ligature then equally successful ? In spite of J. L. Petit's case, 
Dupuytren hesitates, and evidently inclines to the opposite opinion. 
However, except in case of such injury as would render the preser- 
vation of the limb impossible, I confess that I should try the ligature 
before resorting to amputation. 

(6.) Muscular spasm occurs in very variable degrees. " In frac- 
tures of the lower extremity," says Boyer, " and particularly in 
those of the leg, it sometimes happens, during the first two or three 
nights after reduction, that the injured limb is affected with convul- 
sive twitchings, wakening the patient with a start, and deranging the 
fragments so that they must be reduced anew." This remark is very 
true ; I would add that the same phenomenon takes place in some 
patients in whom there is no displacement, and may even in doubtful 
cases strengthen our suspicion that fracture exists. These spasms, 
unless violent, are of trifling importance ; we endeavor to soothe 
them by slightly flexing the leg, with special care that no portion of 
the limb is" wrongly placed ; and at most they call for an anodyne, 
or for an emollient poultice. Violent spasms, interfering with reduc- 
tion, even before the inflammatory period, should be remedied by 
bleeding, low diet, and antiphlogistics ; and I have found it useful to 
add to these means full doses of opium. 

It is so also with cases in which inflammation and fever are pre- 
sent, and particularly when the fragments have torn the integuments 
and protrude externally. Dupuytren, in speaking of fractures of 
the fibula with luxation of the foot and exposure of the tibio-tarsal 
articulation, gives a frightful picture of "the consecutive and per- 
manent pains, resulting from the displacement of the bones, the 
piercing, tearing and distension of the soft parts ; the inflammation, 
swelling and compression increase ; they are accompanied by insom- 
nia, fever, restlessness, spasms, involuntary and constant contrac- 
tions, at each of which the fragments are displaced afresh, and the 
soft parts further injured, and which finally pass into convulsions and 
tetanus unless their cause is removed. Soothing remedies," he adds, 



A TREATISE ON FRACTURES. 231 

"may moderate these symptoms ; narcotics, given in full doses, may 
prevent the pain from being felt ; but as they leave untouched the 
cause and some of its effects, while leading us to trust to an amelio- 
ration which is only apparent, they inspire a false and fatal security. 
Thus it is that we have seen gangrene declare itself without any 
warning pain, in patients whose sensibility was deadened by narco- 
tics given in too heavy doses." 

I agree entirely with Dupuytren concerning the uselessness and 
danger of narcotics under these circumstances, and, indeed, gene- 
rally when fever is developed. But when, immediately after, he 
says that the best means of allaying the disturbance is to reduce the 
fracture, when he says that by so doing we cause the disturbance to 
vanish at once, as by a charm, I cannot too strongly oppose an as- 
sertion so false and a precept so full of practical danger. He gives 
only one case in support of his ideas ; but let us examine into this 
one. 

A young woman, jumping from a carriage, luxated her foot in- 
ward ; the fractured tibia and fibula protruded through a large 
wound on the outside of the ankle-joint. The pain was terrible ; re- 
duction was performed. The pain continued through that day and 
the next, and the patient was tormented with constant spasms ; in 
spite of bleeding and of soothing remedies, they kept increasing, 
eliciting every moment shrieks from the sufferer. On the ninth day 
tetanus set in. 

Now, I ask, could we find a fact which would more grievously con- 
tradict the doctrine ? And yet this is by no means the only such 
case ; I have already quoted two others given by Sir A. Cooper, in 
which reduction was quite as unsuccessful, (see page 166 ;) and mo- 
dern experience has only confirmed the opinions formerly held on 
this point. 

I repeat, then, with Hippocrates, that spasm is so far from being 
allayed by reduction as to constitute a capital objection to any attempt 
at it. What, then, is the course to be pursued ? Place the frag- 
ments in that position in which they will do least injury to the soft 
parts ; resect, if necessary, the protruding portions ; relax the mus- 
cles by semiflexion; and employ bleeding, and the most energetic 
depletory remedies. 

(T.) Inflammation is rarely absent at the outset in fractures with 
displacement. But sometimes it is slight, unattended by redness of 
the skin, and recognised only by the pain, swelling, and muscular 
contraction ; mere rest is sufficient to allay it ; or at most we have 
to employ emollient poultices. If, without involving the skin, it in- 
duces fever, bleeding may become necessary. Lastly, when of a 
still higher grade, affecting the whole thickness of the limb, redden- 
ing the skin, in a word assuming a phlegmonous aspect, we must not 
hesitate to bleed copiously and repeatedly ; but in all cases the sur- 



282 A TREATISE ON FRACTURES. 

geon Bhould remember that the most powerful antiphlogistic is abso- 
lute rest, and that so far from making any traction, or moving the 
limb at all, he should most carefully avoid everything which can 
possibly disturb it. 

Inflammation of much greater severity attends compound frac- 
tures; here, in fact, small as the wound maybe, suppuration is inevi- 
table, and the torn soft parts are in some sort given up to purulent 
deposit. In these cases much value has been ascribed to irrigations, 
constant or occasional, with cold water; at one time they were in 
very general favor. I have had occasion to examine the question 
specially, and a close study of the facts has brought this mode of 
treatment down to its true place. Among thirty compound fractures 
of the leg treated by continuous irrigation, I have found three 
deaths : one was dismissed with non-union and a fistulous wound ; 
three others, after having had chills, fever, abscesses, and sloughing, 
finally reached a cure at from the 172d to the 228th day ; another, 
after having numerous sloughs, was cured, the time not given; lastly, 
five cures were obtained as in ordinary cases. A fracture of the 
arm, thus treated, was attended with chills, fever, and purulent de- 
posits, but healed by the seventy-third day. M. Breschet, to whom 
nearly all these cases occurred, was so impressed by them that he 
has given up the employment of any but warm irrigations. 

Occasional irrigation, by means of compresses moistened from time 
to time, was used with entire success in two cases of fracture of the 
leg, by M. Josse and M. Dubourg ; and on the whole this plan seems 
to me to have as many advantages and fewer inconveniences than 
that of continued irrigation. The latter, however, would appear to 
be more particularly adapted to gunshot fractures of the foot or 
hand; but if we think fit to employ it, we should recollect that the 
chances of success are less in winter than in summer, and that in 
inflammations extending beyond a certain depth, it will only mask 
the symptoms, and should be absolutely rejected.* 

This completes the list of primitive or primary epiphenomena, 
although it has been necessary, in order to avoid too many subdivi- 
sions, to place under the same head such as appear at the time the 
fracture is received, and such as only appear some hours or days 
after. The consecutive symptoms have dates even more various; 
some of them may come on very early, as soon even as some which I 
have called primitive, such as suppuration, and gangrene; others 
always appear later, such as necrosis, fistulae, erysipelas, and local 
scurvy. 

(1.) Suppuration is always of late occurrence in simple fractures, 
while it is really a primary symptom of such as are compound. In 
the latter the pus naturally flows out by the wound, and provided the 

* Malgaigne, De I irrigation dans les maladies chirurgicales, Paris, 1842. 



A TREATISE ON FRACTURES. 233 

fragments are kept perfectly in position, all the surgeon need do is 
to maintain a free exit for the matter, wiping it off as little as possi- 
ble in renewing the dressings, unless it be in excessive quantity; he 
may moderate its amount by emollient applications or by a few 
leeches. The dressings should be very simple ; in many cases a bit 
of lint and a light compress will suffice. 

When an abscess forms at the seat of a simple fracture, we must 
wait till it is mature, then open it freely, and in such a way as to 
favor the discharge. If sinuses form along the limb, we almost always 
have to make counter-openings ; and the indication being once plain, 
we should make our incisions both promptly and freely. 

(2.) Gangrene may be of large or small extent. Sometimes it is 
the direct result of contusion; sometimes of excessive inflammation 
in the limb ; but much more frequently it is from the pressure of the 
apparatus causing sloughs at points which are not well protected, 
such as the heel ; lastly, occasionally the fragments cause it by 
pressure from within outward. On our knowledge of these causes 
is based our prophylactic treatment. As to subsequent treatment, I 
have only one remark to make ; if we would remove the sloughs as 
soon as possible, cleanse the wound, and hasten cicatrization, we 
should resort to emollient cataplasms. If, on the contrary, we have 
any reason for delaying their separation, I have found by direct ex- 
periment that resin-plaster answers this purpose perfectly. 

(3.) Necrosis attacks the ends of fragments which have been de- 
nuded of their periosteum, exposed to the air, or bathed in pus. 
Fig. 7 affords a good example of this; the end of the lower fragment 
of the tibia, and the intermediate splinter, are necrosed, and we see 
in the adjoining portions of the bones the beginning of the work of 
elimination. To wait, trusting to nature, is the most prudent plan; 
the callus will form after the separation is accomplished. S. Cooper 
quotes a case from Schmucker, showing that even a tardy separation 
will not hinder consolidation. In an oblique fracture of the leg, a 
fragment of the tibia became necrosed, and at the end of eight months 
there was still a sinus on each side of the leg. Schmucker opened 
the sinus, and extracted the necrosed portion; when the fracture, 
which till then had remained movable, became firmly united in the 
space of two months. Norris likewise extracted a necrosed portion 
of the humerus four months after the occurrence of the fracture, and 
consolidation subsequently took place in one month. 

(4.) Fistulce. — As long as a particle of necrosed bone is still to be 
eliminated, it is very unusual for the wound to close; but it may 
gradually grow smaller, till it presents merely a fistulous ulcer. 
Some surgeons then think it right to stretch the opening with tents, 
or even to destroy its edges with caustic potash. J. Hunter showed 
this to be unnecessary, and that it mattered little if the opening be- 
came contracted or even closed, so long as the sequestrum remained 



284 A TREATISE ON FRACTURES. 

firm; excepting always in cases where the wound communicated with 
contiguous articulations, as in the foot and hand, or where the pus, 
thus confined, might burrow perhaps from one joint to the other. 
I think it may be stated, as a general rule, that unless the contrac- 
tion of the wound induces some bad symptom, it should be let alone; 
but on the first suspicion of oedema, of inflammation, of alteration or 
stagnation of the pus, the orifice should be enlarged either with 
caustic, or with the bistoury. When, lastly, the splinter is separated, 
it need hardly be said that a sufficient opening should be made, and 
the piece extracted as soon as possible. 

Sometimes fistula are kept up by a foreign body from without, as 
a ball or a bit of clothing; frequently by splinters not taken out in 
the beginning, or which, left adhering, have become detached. The 
splinter may be inclosed between the fragments, as in a case given by 
Faivre. A young man had for seven months suffered from a fracture 
of the tibia caused by the kick of a horse; the bone showed no ten- 
dency to unite, and amputation even had been spoken of. In raising 
the lower part of the limb, Faivre heard a dry sound at the seat of 
the fracture ; having exposed the bone, he found interlocked between 
the fragments a splinter, an inch and a half in diameter, and com- 
prising the whole thickness of the tibia. This was extracted; the 
ends of the bone, seeming to be altered, were cauterized, and six 
months afterwards the cure was complete.* 

In a case of un-united fracture of the humerus, of two months' 
standing, Dr. Isaac Hulse, of New York, took advantage of a fistula 
remaining open to re-establish the work of consolidation. He threw 
in daily injections of a stimulating liquid, at first wine and water, 
then salt and water, and finally a solution of sulphate of copper. 
Union actually occurred in the space of two months, although the 
fistula remained; this was explained when there escaped first a little 
splinter, and subsequently, six months after consolidation, another 
large bit of bone an inch and a half long and an inch wide. The 
account goes no further. f 

When a fistula, ensuing on a compound fracture, stubbornly re- 
fuses to cicatrize, there is always reason to suspect that a splinter 
will sooner or later escape. If this issue is too long postponed, we 
may enlarge the wound down to the bottom, with a bistoury; and 
even if we do not detect the foreign body, this little operation will 
be the best means of causing the fistula to heal up. 

(o.) Erysipelas is one of the most common incidents in compound 
fracture-, and its cause is not always easily detected. Sometimes 
the prolonged confinement to bed results in digestive derangement, 
and the erysipelas then arises from hepatic disorder. At other times 

* Journal ,h Midecine, 1786, tome lxviii, page 210. 

f American Journal of the Med. Sciences, Feb , 1834, p. 374. 



A TKEATISE ON FRACTURES. 235 

we may suspect the stagnation of pus in some nook or recess of the 
wound; often the separation of a splinter of bone. [In the United 
States the general opinion is that erysipelas is a consequence of some 
hitherto undefined atmospheric state, and that any source of irrita- 
tion may be an exciting cause. It is undoubtedly sometimes conta- 
gious, or at least so strongly epidemic as to amount to about the 
same thing ; and we seek to attribute it not to the local injury, which 
may be the merest scratch, but to the more formidable predisposing 
cause; be this latter a peculiar condition of the atmosphere, or of 
the constitution, a contagion, or what not.] Erysipelas of broken 
limbs may be fixed or wandering, superficial or phlegmonous, often 
spreading over the whole member; it almost invariably leaves one or 
more abscesses. I have elsewhere mentioned its unfavorable influ- 
ence on the formation of the callus; we see then the importance of 
studying its causes, to prevent its occurrence or its return. For the 
rest, aside from any special indications referable to the causes, the 
same treatment is called for as in ordinary erysipelas. 

(6.) Lastly, at a more or less advanced period of the treatment, 
the limb may be attacked with local scurvy. The causes assigned 
for the development of this affection sufficiently indicate the course 
to be pursued to prevent it ; when the first symptoms have already 
appeared, we must set ourselves more carefully than ever to guard 
the limb against dampness, to keep it exposed to the air and light, 
and to give a nutritious diet, with tonics and stimulants ; applying 
locally embrocations with tinctures, and with aromatic and balsamic 
substances. M. J. Cloquet has employed these means with success ; 
it has however seemed to me that their action would be much pro- 
moted by first dissipating the oedema. To this end, at first with the 
hands, I press and knead the limb so as to make the serum flow back 
toward the trunk, where it is much more easily absorbed; I after- 
wards continue the process by means of compresses and rollers ; and 
sometimes I have succeeded in twenty-four or forty-eight hours in 
drying the whole limb, so to speak. The integuments having thus 
been somewhat refreshed, are more open to the action of the air, 
of the sun, and of stimulating embrocations; but it is well to bear 
in mind that the effecting of a cure demands often much time and 
attention. 

The constitutional symptoms of fractures are such as attend other 
traumatic lesions. "We shall say a few words only of fever, tetanus, 
nervous delirium, and lastly of sloughing over the sacrum. 

(1.) Primary fever is usually allayed by diet and cooling drinks, 
and only calls for bleeding when some other affection is joined with 
it, such as spasms or violent local inflammation. If there should 
subsequently occur general excitement, gastric irritation, etc., they 
must be treated without reference to the fracture. 

(2.) When tetanus occurs, is there any special indication to be 



286 A TREATISE ON FRACTURES. 

Pound in the fact of the fracture? Larrey tried amputation, and 
appears to have been somewhat successful, especially in chronic 
eases. It would seem indeed that this means attacked the evil at 
>t, and carried out the aphorism, " Sutyatd causa, tollitur ef- 
-." But experience has sadly disappointed these hopes, and 
the failures have been so numerous that the successes obtained can 
hardly be attributed to more than chance. 

(3.) Dupirvtrcn has pointed out another complication, which he 
calls nervous delirium, because it occurs without fever, and yields 
admirably to opiates. He administered by enema, in a very small 
quantity of the vehicle, eight or ten drops of Sydenham's laudanum, 
[vinum opii,] repeating it if necessary three or four times at inter- 
vals of five or six hours. I have found opium given by the mouth 
to afford just as good results. 

[This form of delirium may be distinguished from delirium tremens, 
in that it is not preceded by sleeplessness, the patient often waking up 
delirious, from a very sound sleep ; it is more amenable to small doses 
of opium ; there is far less gastric irritability ; and the form of the 
hallucinations is not so much that of ocular spectra as of general 
excitement.] 

(4.) Finally, it remains for me to speak of an accident which is 
thought to be very common in old persons with fracture of the lower 
extremities, and especially of the cervix femoris; I allude to slough- 
ing over the sacrum. I for a long time entertained the usual idea 
on this point; but having been placed over the surgical wards at 
Bicetre, I was soon convinced that the statements in regard to it 
were exaggerated. Old people endure lying in bed as well as other 
adults; whether they have fractures of the leg or of the cervix 
femoris makes no difference at all. I have treated the latter frac- 
ture in patients of seventy, seventy-five, eighty years, and more, 
without seeing any appearance of either excoriation or sloughing. 
I have also visited the paralytic wards, and seen old people who for 
years had lain upon beds without mattresses, and yet w r ere without 
any sloughing whatever. 

Whence then the common misconception on this point? We have 
seen patients confined to bed by fractures, incidentally attacked with 
some general or visceral affection, as scurvy, pneumonia, diarrhoea, 
etc As soon as fever was thus set up, sloughing rapidly ensued, 
the more rapidly as the patients were thinner; and these exceptions 
were assumed to form the rule. I shall quote here but one single 
instance: an old man of eighty-seven years came into my wards 
June 2, 1841, with fracture of the cervix femoris. He lay at first 
for two months doing well; after this scorbutic spots appeared on 
different parts of his body, but he went to the ninetieth day without 
any sloughing. On that day he had fever ; next day the skin over 
the sacrum was broken, and four days after, when he died, there was 



A TREATISE ON FRACTURES. 23T 

a slough as large as a man's hand, at that spot. But is this peculiar 
to old people? I have often had proof to the contrary, and there 
was at that very time among the paralytics at BicStre a young man 
of thirty who had had his spine fractured by a land-slide; in the 
course of his treatment, he was attacked by a high fever, and had 
sloughs over the sacrum ; afterwards, the fever having subsided, the 
sacrum was again covered over by good solid cicatrices, notwith- 
standing the obstinate persistence of the paralysis. 

I hold then that neither the age of the patient nor the nature of 
the injury is sufficient to account for the formation of sloughs over 
the sacrum, and that these are always the result of some general 
affection. This would serve as a guide to our prognosis in some 
cases, and enable us to ward off the accident. Thus, if the general 
condition is good, even the oldest subjects endure extremely well 
confinement to an ordinary bed. If we have a compound fracture, 
with abundant suppuration, to deal with, especially in the lower ex- 
tremity; or in the simplest fractures, if high fever comes on, we 
should hasten to relieve the sacrum from all pressure, by using a 
perforated cushion or mattress, or a mechanical bed. These pre- 
cautions become still more indispensable after the sloughs have 
formed, to prevent their increasing in extent and depth; in severe 
cases we should even use Arnott's water-bed. Here particularly we 
wish to postpone as long as possible the separation of the slough, lest 
the pain and suppuration should speedily exhaust the patient; and 
for this purpose, experience has long since shown that it is best to 
cover the spot with a piece of lead-plaster. 

§ XII. — Of Convalescence from Fractures. 

"When the time usually required for consolidation has elapsed, we 
remove the apparatus, and ascertain as far as possible that there is 
no mobility of the fragments; and we then allow the limb gradually 
to assume its ordinary functions. But this last point requires some 
precautions of no small importance. 

When we have to deal with a simple fracture, without displace- 
ment, in the upper extremity, the period of treatment not having 
exceeded one month, and the articulations having been kept semi- 
flexed, the patient can generally use the limb immediately ; at most 
it is necessary that he should for a day or two carry it in a sling, to 
prevent fatigue. In the lower extremity, after a simple fracture of 
the tibia or fibula, it is nearly the same; although here we must re- 
collect that the limb has to support the weight of the body, and 
must give it for several days the assistance of two crutches. Con- 
valescence is always speedy. 

When the fracture has involved either the femur or both bones of 
the leg, it is better before the patient attempts to walk even with 



238 A TREATISE ON FRACTURES. 

crutches, to make him keep his bed some time, with the limb entirely 
unconfined, in order to exercise it without resting any weight upon 
it. These motions will give suppleness and strength to the limb 
without endangering the newly formed callus, and the plan can at 
least do no harm. However, the first time the patient quits his bed, 
W6 must expect at least one of the following phenomena to occur: 
redness of the limb, cedematous swelling, and a peculiar feeling of 
insecurity. 

The redness is from the prolonged rest in the horizontal posture ; 
the capillary and venous circulation seems to have lost its force; 
those vessels become turgid, and hence a redness more or less intense, 
sometimes purplish, sometimes bluish. Frictions with the hand, fre- 
quent use, the horizontal position when the redness becomes exces- 
sive, and lastly, if necessary, a roller applied so as moderately to 
compress the foot and leg, will generally overcome this symptom in 
a few days. 

The oedema seems to proceed from the same cause, although it 
sometimes comes on without any redness. The treatment is the 
same; but the compressory bandage is indispensable for a few days. 
We may also use frictions with camphorated brandy, with aromatic 
wine, etc. According to my experience, dry frictions are quite as 
efficacious; but I am also convinced that they seem to the patient to 
be too simple, and are often neglected; I therefore take care to pre- 
scribe some medicinal liquid, with the sole object of making sure of 
the frictions. 

The extreme timidity of patients about the use of their limbs, is a 
phenomenon which has received too little attention from surgeons. 
It sometimes depends on purely material causes, such as the weak 
and atrophied state of the muscles, the stiffening of the joints so 
that every motion to any extent induces pain, and lastly real pain, 
with a feeling of weakness, at the seat of fracture; I shall recur 
directly to each of these points. But apart from all these causes, 
there often remains in the patient's mind a mistrust purely moral, 
an instinctive fear that the limb has not sufficient strength to 
sustain him. This fear lessens and passes off in time, it is true; 
but sometimes convalescence is singularly retarded by it. Here the 
surgeon must interfere, must inspire security, must if needs be force 
it; for reasoning alone hardly ever avails against instinct. I have 
often seen, in my wards, patients furnished with crutches hold the 
foot up from the ground for eight or fifteen days. I tell them to 
rest upon it ; — Monsieur, it is impossible. I take away one crutch, 
they grasp the foot of the bed, wavering, fearing to fall. Walk! — 
It is impossible. I bring them into the middle of the room; I tell 
them there is no danger ; I push and urge them ; — they walk as if 
stupefied. I take the other crutch from the armpit, make them 
grasp it like a cane ; — they again resist, saying it is impossible. How- 



A TREATISE ON FRACTURES. 239 

ever, they walk; then I take away the stick and reach out one finger 
for their support ; — they walk again. I withdraw the finger, and they 
still walk. I tell them to run, and they run. To remove all pre- 
text for any new fears, I make them jump, first on the sound and 
then on the fractured limh; in the space of a few minutes, these men 
who could not walk with two crutches, thus run and jump without 
any crutches at all; their courage is entirely restored. It is well 
however, after this trial, to leave them the use of one crutch to save 
the limb from being too much fatigued ; but we may be sure they 
will not employ it longer than is necessary, and will soon throw it 
aside of themselves. We must also, before making this trial, be well 
assured that the want of confidence is purely instinctive, and not 
founded on one of the three material causes which remain to be con- 
sidered. 

Atrophy of the limb may proceed from long-continued suppura- 
tion, from excessive pressure of the apparatus, or even from too pro- 
longed inaction, especially when the air is excluded, as in an immov- 
able apparatus. Frictions, douches, but always, and above all, 
exercise, are the best remedies for this ; the exercise must, however, 
be adapted to the weakness of the limb ; it should not be too violent, 
for fear of falls, nor too long-continued, for fear of fatigue. Atrophy 
is singularly favorable to oedema ; hence it is necessary before the 
patient rises to envelope the leg in a moderately tight roller, which 
may be removed when he lies down again. The pressure is dimin- 
ished from day to day, according to circumstances ; and we carry 
the bandage also to a less and less distance up the leg'. We also 
allow the patient the sun, fresh air and a nutritious diet. 

Stiffening of the joints is one of the most annoying, and at the 
same time one of the most common, sequences of the usual treatment 
of fractures. I have pointed out the chief causes of it : inflamma- 
tion, the extended position, pressure from apparatuses improperly 
made to surround the limb. The stiffening is so much the more 
marked as the contusion has been more severe, the fracture nearer 
the joint, the immobility more prolonged. Boyer has observed that 
it is much more considerable in the lower than in the upper articula- 
tion of the bone. It may attack also the most distant joints, if these 
have been kept confined. 

It is very important to prevent this from occurring. We therefore 
leave the joints free from all pressure, keeping them in a medium 
position, and using occasionally passive motion. These motions 
should be so made as not to involve the fracture ; hence it is neces- 
sary either that this should be firmly secured by the apparatus, or that 
consolidation should be somewhat advanced ; and the surgeon should 
intrust it to no one but himself. 

If, notwithstanding these precautions, stiffening will sometimes 
occur, we may judge of what takes place when they are neglected. 



240 A TREATISE ON FRACTURES. 

The fracture ia cured, but the patient remains as powerless, or more 
so. than he was before. To carry the hand to the head, to put the 
foot on the ground, involves stretching of the ligaments, and pains 
like those of the rack; it is fortunate if real anchylosis does not 
ensue. 

Two opinions have prevailed among surgeons concerning the treat- 
ment of false anchylosis. Some think that time alone will effect the 
cure, and leave their patients to this too often delusive hope; others, 
a little less confident, still know of nothing better than to employ 
frictions, emollients, baths and douches; baths of blood, of sulphur- 
ous or other waters, etc. Now nothing can be more empirical and 
dangerous than are these two plans of treatment. The only efficient 
remedy for stiffening of a joint is exercise; baths and douches can 
only soothe pain and favor these motions. If, then, we leave a pa- 
tient to himself with a slight stiffening, which does not hinder spon- 
taneous motion, time, added to the natural exercise of the limb, may 
suffice to overcome it ; if it is more marked, neither time nor the 
unaided efforts of the patient will completely attain this end. If, 
lastly, it is still more serious, the patient being unable to execute any 
motion by himself, to send him to thermal springs is merely to con- 
demn him to an incurability, the more certain since he is made to 
waste in frivolous attempts the time so invaluable for really effecting 
a cure. I have before cited several such cases, (see page 100 ;) the 
one I am about to relate will serve to show all the danger of delay. 
A planter in Havana had sustained a fracture of the cervix humeri ; 
during the entire treatment his hand had been kept extended, and 
applied to his chest ; when the apparatus was removed, his fingers 
were stiff, and entirely inflexible. He was given to believe that time 
would restore him the use of them ; but several months having gone 
by without any improvement, he was sent to Bareges, [a village in 
the Upper Pyrenees, where there are sulphur springs.] He came 
thence to France, and consulted me at Paris. Seven or eight months 
had elapsed since the accident ; I considered that there was no time 
to be lost, and urged him strongly to remain in Paris. But he had 
reasons for returning to the Pyrenees ; there he lost three or four 
months, and came back in apparently the same state, but in reality 
with the stiffness increased by its duration. I then tried in vain all 
the means, cataplasms, frictions, inunctions of oil, to favor the move- 
ments which I daily attempted ; slight movements availed nothing ; 
the use of greater force brought on swelling and pain, and had to be 
abandoned. Finally, after a whole month of attempts and sufferings, 
the patient, although firm and courageous, was unwilling to perse- 
vere ; preferring to retain his crippled hand rather than undergo the 
cruel pain of a treatment the result of which I could not guarantee. 

Hence the surgeon, as soon as the apparatus is taken off, should 
move the joints, forcing those which are stiff, and advise the patient 



A TREATISE OX FRACTURES. 241 

to continually exercise them in this way. Next day, and the days 
following, he should keep it up, until the articulations have recovered 
their full freedom. 

Lastly, patients often complain of pain and a feeling of weakness 
at the seat of fracture; we should then be cautious in making forcible 
motion, and in bringing the weight of the body to bear on the limb : 
for almost always this pain indicates a yet incomplete callus. From 
neglecting this sign, the callus has been more than once distorted, 
the fragments separated or overlapped, and an unexpected mobility 
brought on. But in such a case, strictly speaking, the fracture has 
not jet arrived at the period of convalescence, and these hindrances 
to consolidation require to be discussed separately. 

§ XIII. — Of Hindrances to Consolidation. 

Between a simple delay in consolidation of the callus and the 
establishment of a pseudarthrosis there is, as we have already had 
occasion to remark, an essential difference ; unhappily the diagnosis 
between these two conditions, always difficult, is sometimes impos- 
sible ; indeed, the surgeon can only be safely guided by the length 
of time which has elapsed since the fracture, and the inefficiency of 
rational treatment. 

Hence we see the importance of knowing and using these means, 
since for want of them the most expert surgeons have more than 
once diagnosed pseudarthrosis, and been led to perform operations 
which were, to say the least, unnecessary. I do not deny that there 
is something arbitrary in classing as cases of simple delayed union 
all those which have been curable without operations, and thus to 
circumscribe pseudarthrosis by the necessity of resorting to such 
measures : nor would this accord with generally received ideas. But, 
I repeat, the difficulty of the diagnosis is such that it has not seemed 
to me to be otherwise soluble ; and moreover, I believe that this view 
is of real utility in practice. 

When, therefore, a fracture does not become united in the usual 
time, the surgeon should first of all seek for the reason, in order to 
combat it directly. He will therefore inquire if the patient has had 
a due amount of nourishment. If necessary, he will recommend 
change of air ; and even guard against any morbid moral condition; 
Marrigues reports the case of a peasant in whom the only cause of 
delay seemed to be chagrin at finding himself in a hospital. The 
same author observed, in a young man aged 18, the callus retarded 
for over eight months by repeated masturbation, and only succeeded 
in effecting a cure by having him closely watched ; and M. A. Thierry 
has related two analogous cases.* We are to address remedies, if 

* Marrigues. Diss, sur la formation et les differ, vices clu cal, Paris, 1783; 
A. Thierry, Experience, Nov. 4, 1841. 

16 



248 A TREATISE OX FRACTURES. 

irvv, syphilis, or any general affection which may 
interfere with union. The state of pregnancy calls only for patient 
waiting. an«l for the most generous diet possible ; if the woman is 
nursing, the child must be taken from the breast. 

It is important also to remedy local affections, whether of the soft 
parts, as .edema, local scurvy, or ulcers ; or of the fragments them- 
BeWes, afl BJ si - 5, caries, necrosis, hydatids, etc. Sometimes the 
evil is undoubtedly incurable, and we are obliged to amputate; but 
we must not give up too soon. A young man eighteen or twenty 
years of age had caries of the middle portion of the tibia ; a fracture 
occurred at this part. J. L. Petit removed the fungous granulations, 
took away some of the carious bone with a trephine, and applied the 
actual cautery to the remainder ; the result was a good cicatrix. 
Hydatids would perhaps be a graver complication, to judge at least 
from the one case given by Dupuytren. It concerned a fracture of 
the humerus in a man of twenty-three ; at the end of eleven months, 
the callus being still unformed, Dupuytren resolved to resect the 
broken ends. The upper one was resected first ; on examining the 
other, the operator was amazed to find it dilated into a kind of pouch, 
within which existed a prodigious number of hydatids : these were 
extracted as far as possible. Resection of this fragment was not 
performed ; the suppuration went on. and the patient having suc- 
cumbed, this portion of the bone presented a vast cavity without any 
trace of marrow or of medullary membrane. It is easily seen that 
under such circumstances the chances of union would be much di- 
minished, and that at least it would be necessary to resect a very 
large part of bones thus altered. 

But it is infinitely more common for union to be delayed, either 
from the obliquity of the fracture and the separation of the ends, or 
becau- not sufficiently maintained : or, lastly, by excessive 

moistening, by too tight or too early bandaging, or by dressings kept 
on too long, the atrophied or cedematous limb having lost the vigor 
essential to the restoration of the bone. From these various circum- 
stances there arise naturally various indications, which may be ar- 
under four heads : (1) to insure for a sufficient length of time 
the immobility of the limb; (2) to keep the fragments together by 
to exeite the vitality of the part by local means; 
the syste?n at large. 

The first indication calls imperatively for the application of firm 
able neither to relaxation nor to derangement; we should 
in thes scard all cushions, slings and boards. Good strong 

splints, and an apparatus properly solidified with white of eggs] 
starch, or dextrine ; plaster moulds: permanent extension rigorously 
maint: ry. cuirasses to confine at once the trunk 

and the limb ; these are our safest resources. If the limb seems 
sound, and sufficiently vitalised, and if the delay of union has no other 



A TREATISE ON FRACTURES. 243 

cause than the insufficiency of the external applications used, the im- 
movable apparatus will be effectual ; and nowhere, perhaps, is it so 
clearly called for. The case is quite otherwise when the atrophied 
or cedematous tissues require the salutary influence of the air and 
light ; splints retained in place by strips of lead-plaster are then far 
preferable. Ununited fractures of the femur or humerus sometimes 
render necessary an immobility of the trunk, only to be derived from 
permanent extension or from cuirasses, and then we should not hesi- 
tate to resort to these. The successes thus obtained are so frequent 
that any surgeon can cite them ; but I would add that there would 
be still fewer failures if we had more perseverance. 

A young man of nineteen or twenty was treated at La Charite for 
fracture near the middle of the femur ; at the end of four months the 
fragments were still very movable. The consulting surgeons pro- 
posed various operations, but were generally agreed that a false joint 
was inevitable, and that the patient must remain crippled. At the 
earnest entreaty of the uncle of the young man, Boyer undertook 
the case ; he adapted continued extension to the ordinary bandage, 
which he carefully examined and tightened daily ; and at the end of 
three months of this treatment, the fracture was firmly united. 

A painter, thirty-two years old, broke both thighs by a fall. He 
was treated at the Hotel-Dieu at Lyons, by splints and permanent 
extension, but no callus formed, and on the ninety-sixth day there 
was still the most complete mobility between the fragments. 
M. Bonnet resorted to the starch-bandage with flexible splints. This 
apparatus being taken off at the end of two months, consolidation 
was no more advanced than before. The patient was now placed in 
the grande cuirasse of M. Bonnet, confining at once the trunk and 
both the lower limbs. About fifty days afterwards, the fracture of the 
right thigh was consolidated ; that of the left did not unite till three 
months and a half later, the apparatus having been so altered as to 
make the compression more exact. This very tardy cure only shows 
how much perseverance will do for both surgeon and patient. 

Another account given by M. Bonnet, regarding a fracture of the 
humerus, is no less encouraging and instructive. A child eleven 
years old had the arm crushed by a wagon running over it, immedi- 
ately below the insertion of the pectoralis major. A good many 
splinters came away, and the fistulous openings closed; but after 
six months' steady use of splints, the fragments were still entirely 
movable. The starched bandage was now applied for six weeks with 
no better success. M. Bonnet then tried his cuirass, which was kept 
on for about three months, and at last effected consolidation.* 

In one of these cases it was necessary to employ a certain degree 
of compression, but only in order to insure the absolute immobility 

* Bonnet, M4rn. cit6, Gaz. Medicate, Sept., 1839. 



244 A TREATISE ON FRACTURES. 

of the fragments. It is with another view that Amesbury has ex- 
tolled local pressure; according to his theory immobility is doubtless 
indispensable, but another no less essential condition is a sufficient 
excitation of the parts; and it is this excitation which he mainly 
aims at in making pressure, procuring at the same time also the ab- 
sorption of the fibrous substance developed between the fragments. 

Amesbury obtained this pressure in several ways. Most commonly 
he made it transversely, either by tightening a little more his or di- 
nar v apparatus, composed of splints held together by straps and 
buckles, or by adding to it, as accessory, a sort of tourniquet worked 
by a screw. Sometimes also he judged it necessary to push the 
fragments together endwise ; for example in the humerus, by raising 
the elbow with a short sling; in the leg, by means of a strap going 
round the sole of the foot and buckled to a brace above the knee. 
Dr. Wright, of Baltimore, U. S., sometimes used with success simple 
compresses, sometimes short pasteboard splints arranged around the 
fracture and held in place by a roller.* His most marked success 
was in a case of fracture of the tibia of fourteen weeks' standing. 
But Amesbury gives sixteen observations of fractures of the fore- 
arm, leg, humerus, and femur, of from two to sixteen months' stand- 
ing, consolidated by means of pressure in from three to ten weeks. 

He has however met with two cases in which it failed; one a frac- 
ture of the humerus, the other of the femur. In these two patients, 
the mobility was extreme ; the arm bent at the seat of fracture with 
as much facility as at the elbow, and the fragments of the femur 
could be freely separated in all directions. The author thinks that 
in such cases as these, there is formed between the fragments an 
artificial capsule filled with synovia; but this needs proof. Still, 
however this may be, the obstinacy of these excessively movable 
fractures is an important fact in respect both to our treatment and 
to our prognosis. 

[In an article published in the Am. Journ. of the Med. Sciences for 
Jan., 1855, Dr. Henry H. Smith, of Philadelphia, proposed remedy- 
ing pseudarthrosis by means of a sort of artificial support, adapted 
to the limb in such a way as at the same time to render the frag- 
ments immovable and to enable the patient to make some use of the 
limb ; details of seven cases successfully treated by this method are 
there presented.] 

As has been seen, Amesbury endeavored to keep the fragments 

together, and also to obtain the absorption of the intermediate fibrous 

; but he thought also to induce a new sftper-excitation, and 

hence he carried the pressure so far as even to cause pain. This 

latter idea has almost always prevailed among practitioners, and to 

* Wright, Remarques sur la reunion des os frad., Journal des ProgrZs, 
tome xv, p. 88. 



A TREATISE ON FRACTURES. 245 

it are due all the operations of which we shall hereafter speak. To 
it also are due the trials of the more innocent local applications, 
which are not always without efficacy ; such as stimulating lotions, 
vesications, the actual cautery, and electricity. 

M. Jobert, struck like many other surgeons with the delay of con- 
solidation induced by bandages either too tightly applied or excluding 
the air too completely, has sought to remedy their effects by reducing 
the apparatus to. a splint loosely confined by a few circular turns at 
its extremities merely, and moistening the limb with camphorated 
brandy or a vinous decoction of red roses; and in this way he has 
obtained solid union in fractures of more than four months' standing.* 
This is precisely the treatment recommended by M. J. Cloquet for 
local scurvy. Buchanan, in 1828, tried with some success the 
tincture of iodine, applied daily over the seat of fracture by means 
of a small hair-pencil; and others, following his example, have 
likewise found reason to be satisfied with it. 

Vesication was proposed by Walker, of Oxford, in 1815. He 
used small blisters five or six times repeated, and Brodie states that 
he has derived very good results from them even in pretty old frac- 
tures, f Hartshorne, of Philadelphia, tried cauterisation with caustic 
potassa, in 1805, with complete success in two cases, and partial 
success in a third. J Birch, of London, has tried electricity, and 
twice with apparent success ; but Mott, imitating him in two cases, 
used the most powerful charges without effect. 

Lastly, it has been thought, and doubtless correctly, that the 
general condition of the economy might have some influence upon 
consolidation, and recourse has been had to bitters, to quinine, 
and, even without any symptoms of scurvy appearing, to anti-scor- 
butic wine. Saucerotte relates a case of delayed union, which he 
says was at length brought about by the use of a decoction of mad- 
der^ Fabricius Hildanus recommends strongly the employment of 
the stone osteocolla, either in powder, in wine or in tisane. Pare' 
ridiculed the use of this substance, and some may be surprised to see 
it mentioned seriously here. We must, however, observe that the 
facts related by Fabricius bear the impress neither of lively en- 
thusiasm nor of blind credulity. I do not know what was the exact 
nature of this stone; Fabricius merely remarks that it is soft, fria- 
ble, bituminous, soluble in water, becoming hard and losing its pro- 
perties by exposure to the air. It is singular enough that in the 
time of Rhazes, Albugerig recommended, to soothe pain and hasten 

* Bleary, Quelquei COtutid. sur les causes qui peuvent retarder ou empecher 
la consolid. ae8 fractures, Archiv. de M6decine, Aug., 1837. 

t Journal G&n&ral de Medecine, tome ii, p. 340. See also for all the English 
and American observations, etc., NTorris'a memoir, already quoted. 

J [Eclectic Repertory, vol. iii, p. 114; Phila., 1813.] 

\ Saucerotte, Mel. de Chirurgie, 1801, p 418. 



246 A TREATISE ON FRACTURE?. 

consolidation, the internal use of a sort of natural bitumen called 
ununi't, which Avicenna also mentions as an admirable remedy. 
Without claiming for them any specific virtue, perhaps medicaments 
of this kind may have a stimulating action not to be undervalued. 
1 once gave tar-water to a woman who had a fracture of the leg 
which was very slow to unite. The callus at last formed; I cannot 
Bay how far it was owing to the tar-water, but I should ascribe at 
least as much efficiency to it as to a tisane of madder, or any other 
bitter drink. 

But there remains to be mentioned one other internal remedy, the 
efficacy of which is sometimes most remarkable, — mercury given to 
salivation. I do not refer to cases such as those narrated by Ravaton 
and Swediaur, in which the previous existence of syphilis calls for 
specific treatment. After having obtained some analogous successes, 
Fleury, one of my teachers, and surgeon-major at Val-de-Grace, 
recommended mercurial salivation in all cases of retarded consolida- 
tion, saying that it acted by metasyncrisis. [Restoration of the 
normal atomic composition of the system, altered by disease.] It 
would seem that for some years mercury has had its supporters in 
England, even in cases exempt from any suspicion of syphilis. In 
1830, according to Norris, Sir Stephen L. Hammick spoke highly of 
its use in either large or small doses, according to the necessities of 
the case; Collis twice succeeded with it; B. Cooper has given an 
account of a woman aged 28, having a fracture of the humerus of six 
months' standing, treated in vain by compression, the seton, the 
albuminated and the plaster apparatus, and finally cured in one 
month under the influence of mercurial salivation.* It must how- 
ever be added that this remedy may, like others, fail; Arnott and 
Ch. Hawkins have tried it without success. 

§ XIV. — Of Operations for the Cure of Pseudoarthrosis. 

For a long time the only operation for pseudarthrosis known in 
surgery was that extolled by Celsus, the rubbing together of the 
fragments ; and it was not till 1760 that other methods were intro- 
duced. We shall study them in the following order: (1) rubbing the 
fragments together ; (2) needles; (3) the seton; (4) the ligature; 
(5) resection; (6) abrasion or scraping the ends; (7) cauterisation. 

(1.) Rubbing the fragments together. — "If the fracture be an 
old one," says Celsus, "the limb should be stretched so as to break 
up the new tissue; the fragments should then be separated with the 
hands, and rubbed one upon the other, in order to make their sur- 
ough, to destroy their polish, to reduce everything as it were 
to the recent state ; but great care must be taken not to injure either 
the nerves or the muscles." 

* Guy's Hospital Reports, 1837, p. 399. 



A TREATISE ON FRACTURES. 247 

This plan, although much spoken of, has been very seldom put in 
practice.* The first instance I know of was published by Bonn in 
1783, and since then we hardly find ten reported, although among 
these the majority were successful. The two following cases will 
give an idea of the variety of modes in which the method may be 
applied : 

A man aged 44 had had his leg broken by the kick of a horse ; 
the apparatus used having been inefficient, he had still, at the 
end of six months, no union, and a notable degree of overlapping. 
Derrecagaix arranged, below the knee and above the malleoli, two 
strong leather collars with rings at the sides to receive bands ; the upper 
pair of these bands were attached at the head of the bed, the lower 
to a tackle for extension; this latter was pulled on by three assist- 
ants, developing really an enormous power. The leg being brought 
to its normal length, the surgeon rubbed the fractured surfaces very 
forcibly together; after which he applied a bandage with adhesive 
splints, supported by large splints. The fever, he adds, ivas not 
high, nor the pain considerable. By the fortieth day the leg was 
firm enough for the patient to raise it without any apparatus, and in 
less than three months he walked without crutch or stick. f 

A man aged 30 had arrived at the ninetieth day of a fracture of 
the humerus, without any union. Without previously making any 
extension, Kirkbride rubbed the ends of the bone together with 
considerable force for some minutes. This having caused no pain, 
it was repeated every day for a week; the parts having now become 
somewhat sensitive, during the following week the rubbing was per- 
formed only every two days ; afterwards splints were applied. A 
month more, and union was far advanced; at the end of the second 
month it was complete. J 

Another mode of treatment, compared by its own author to that 
of Celsus, was devised by White in 1768. A farmer, forty or fifty 
years old, had a fracture of the thigh of six months' standing, which 
refused to unite. White enveloped the thigh in a laced leather 
sheath, reaching from the pelvis to the condyles of the femur, and 
firm enough to keep the bone straight ; he then made the patient 
walk with crutches. In less than two months the callus had begun 
to form : one month later it was solid ; and it was unaffected by a 
large abscess which occurred in the thigh. 

Although the very occurrence of this abscess would seem calculated 

* In a memoir, addressed to the Academy of Surgery in 1763, Legrand of 
Aries reports three cases of non-union, for which he had known of no treatment. 
In 1780, Sue communicated to the same body some other cases nearly as much 
wanting in respect to treatment. See the Clinique of Desault, by Cassius, tome 
ii, p. 312. 

f Journal de Mtdecine, by Corvisart, etc., tome i, p. 202. 
• % Am. Journal of the Med. Sciences, Feb., 1835. 



24S A TREATISE ON FRACTURES. 

t<> discourage White in his practice, he has been imitated by several 
Burgeons. According to S. Cooper, in his reports of some cases of 
non-union of fractures of the leg and thigh, J. Hunter recommended 
making the patient rise and try to walk, the limb being surrounded 
with splints, in order to produce the necessary degree of irritation. 
Sir Everard Home and Inglis, in England; Kluge, in Germany: 
Champion and Jacqnier, in France, have also had remarkable success 
with this plan. It does not however follow that this means should 
be suitable in all cases. To say no more of the abscess in White's 
patient. Sue has related the case of a man with pseudoarthrosis in the 
femur, for whom Perron, at about the same time as White, had a 
sort of thigh-piece made; but this hindered the circulation so much, 
and caused so much pain when the fragments rubbed one against the 
other, that it could not be endured.* 

On the whole, however, we see that the successful applications of 
this method in the lower extremity are quite numerous. Something 
similar has been tried in the upper extremity: but here of course 
the effect would be simply that of compression, without the mutual 
rubbing of the broken ends, caused in the leg or thigh by the weight 
of the body, and by walking; so that failure has often ensued. Briot 
relates that, for two cases of fracture of the humerus, with loss of 
substance and delayed union, occurring in soldiers, he had two pairs 
of semicylinders constructed of sheet-iron; each pair was stuffed on 
the inside, and completely surrounded the arm, being confined to it 
by bands tightened at will by the patient. He had in view only the 
external support of the arm; in one of his patients he obtained a 
kind of callus. He prescribed a similar apparatus for a fracture of 
the forearm ; but consolidation did not occur. More recently, Baillif, 
of Berlin, constructed something almost exactly like this for two 
patients sent to him, one by Kluge and the other by Rust : one, with 
a fracture of the arm, was not cured; in the other, who had a frac- 
ture of the forearm, three months sufficed for complete union. t 

_ X., dies. — In 1837, I tried to introduce acupuncture needles 
between the un-united ends of a fracture at the inferior fourth of the 
femur; but although movable, the fragments were so close together 
that of thirty-six needles entered at different points, I could not 
make one pass between them. M. Wiesel succeeded better in a frac- 
ture of the forearm nine weeks old. He first passed between the 
fragments of the ulna two needles long enough to go entirely through 

W] /.;,•-</. 1770. p. 75; Hunter's Complete Woi'ls, trans- 

lated into Freneh, vol. i. p. 561 : Inglis, Observ. on the Cure of Unnatural Ar- 

. Journal, 1805, voL i, p. 419 ; Journal 
tome x. ]». 258 ; Velpeau, MSdecine Optratoire. second ed.. tome ii. 
. etc.. in the Clinique of Desault. tome ii. p. 312. 
' ■' •-. • .n France, etc.. 1817, p. 411 ; Jour ' 
. 



A TREATISE ON FRACTURES. 249 

the false joint ; they were allowed to remain for six days, and then 
removed, their presence having brought on considerable pain and 
swelling. Five days later, the same was done with the radius. A 
simple bandage was applied, and in the space of six weeks consolida- 
tion was complete.* 

(3.) The Seton. — A. L. Richter dates the conception of this plan 
as far back as 1T87, attributing it to Winslow, on the authority of a 
Danish journal which I have not been enabled to consult. It would 
appear also that Percy attempted it in 1799, but rather to procure 
the elimination of some adherent splinters than directly to induce con- 
solidation ;t and Dr. Physick, of Philadelphia, who in 1802 used the 
seton in a case of actual pseudarthrosis, should be regarded as the 
author of this method. Since that time, the seton has been employed 
by many surgeons, in various modes and with various results. 

The first operation of Dr. Physick was a very simple one. Having 
a fracture of the humerus to deal with, he caused extension to be 
made so as to put the fragments in relation, and then passed between 
them a seton-needle armed with a silk ribbon, carefully avoiding the 
course of the vessels, and choosing for the points of entry and exit 
the least fleshy parts of the arm. This seton was kept in for five 
whole months, and only withdrawn when consolidation was com- 
pleted. 

In the thigh, it would be difficult so to pass the seton without 
having previously exposed the fracture by an incision; and Norris 
mentions such an operation, performed by Physick himself in Feb- 
ruary, 1810. I do not know that he had been anticipated in this, 
which seems to have been imitated by several surgeons. We may 
derive a just idea of it from the following summary of one of Ward- 
rop's cases. 

The fracture, of twenty months' standing, was seated three and a 
third inches below the great trochanter, and the shortening amounted 
to three and a third inches. Owing to the patient's fleshiness, the 
exact state of things could not be ascertained; the upper fragment 
could be very well traced throughout, under the rectus muscle ; the 
inferior was buried in the tissues ; but their connection was so loose 
that moderate extension brought down the thigh to its normal length. 
TYardrop made an incision of nearly two inches along the outer 
edge of the rectus muscle, just over the upper fragment, which was 
thus exposed. The forefinger being passed in by this wound, served 
as a director upon which to divide with a probe-pointed bistoury the 
soft parts still concealing the lower fragment. The finger having at 
length reached the fibro-cartilaginous substances lying between the 
two ends, the operator carried in first the blunt sheath of the seton- 

* Journal de Chirurgie t 1844, p. 85. 
f Laroche, These inaug., Paris, an xiii. 



250 A TREATISE ON FRACTURES. 

needle, and having well determined the point of introduction, pushed 
the needle itself through this intermediate tissue, downward and out- 
ward, so as to make it emerge below the vastus externus muscle. 
The Beton was then drawn through; but before the apparatus could 
be put on, a jet of arterial blood appeared at the upper wound. It 
came from the bottom of the wound, and the surgeon was obliged to 
carry in his finger, and thus to compress between the thumb and 
forefinger the soft parts at the outside of the thigh for more than 
half an hour. The bleeding being at last arrested, permanent ex- 
tension was tried, but the patient could not endure it. Eight days 
after, it was attempted again, but had to be again given up; and 
ordinary splints were used. The seton was withdrawn on the twenty- 
first day, and consolidation seemed going on well, when two succes- 
sive attacks of erysipelas destroyed twice the newly-formed callus. 
On the whole, the success was very incomplete, the thigh not acquir- 
ing firmness enough to support the weight of the body.* 

We see that besides the incision, Wardrop's plan differs from Phy- 
sick's in the much earlier removal of the seton; the latter commonly 
leaving it in place four or five months, or even more; the former 
being satisfied with some weeks, and even in one case removing it at 
the end of eight days. Moreover, the length of time for the seton 
to remain in seems to be almost entirely optional; in some cases it 
was left for one, two or three weeks; in others one, two, three, four 
or five months ; Liston mentions one in which he kept it in for thir- 
teen months. 

Norris has examined the results of this method, independently of 
its special modifications; and has deduced a statistical table com- 
prising forty-six cases. His summary is very incomplete ; for plac- 
ing together only the cases mentioned in his own memoir I find 
seventy-two cases, as follows: 

30 fractures of the humerus 13 cures, 

18 " " femur 9 " 

14 " " leg or tibia alone - - - 13 " 

6 " " forearm, or one of its bones, 6 " 

2 " " clavicle - 2 " 

1 " " lower jaw 1" 

1 " " acromion 0" 

We may derive some useful information from this table; we see 
how much more readily false joints may be cured in the forearm and 
leg than in the humerus and thigh. But what effect has each mode 
on these results? 

The previous incision would seem to have nothing to do with 
the ultimate result; of twenty-one thus operated on, Norris gives 
seventeen cures and one death; of twenty-four treated without it, 

* Medico-Chir. Transactions, vol. v, p. 358. 



6 failures, 


1 death 


8 


1 " 


1 


" 





" 





" 





" 





1 " 



A TREATISE ON FRACTURES. 251 

eighteen cures and one death. It is however better to employ the 
needle alone, when we can direct it with certainty. 

A more important question is as to how long we should keep the 
seton in. We cannot here establish a parallel between two methods 
merely, since in this respect surgeons have adopted such very dif- 
ferent views ; I have however collected some facts which may throw 
light on the question. Liston, who advises the removal of the seton 
on the eighth or tenth day, has thus treated successfully a fracture of 
the forearm.* Others have succeeded in cases of fracture of the leg 
by. leaving the seton in from twelve to fifteen days. To be sure, these 
varieties of fracture yield more readily than others; and it is mainly 
between those of the humerus and femur that the comparison is of 
interest. Now, let us see how the case stands : 

Seton kept in for — Fractures Treated. Results. 

StolOdavs, - {3 of the humerus, 2 cures. 

J ' } 1 " " femur, - • - - 1 " 

13 to 14 days, 2 " " " " - - - - 2 " 

oo tn on j„ , f 2~ " " humerus, - - - - 1 " 

- t0 dU da ^ s ' " " " " 1 2 « « femur, .... neither cured. 

9*Aia™wi. B I 6 " " humerus,- - - -" 3 cures. 
2 to 13 months, - - - j 4 „ « femm . ' 3 „ 

To sum up, the seton retained one or two weeks has given, in 
six cases, five cures; and from three weeks to thirteen months, in 
fourteen cases, seven cures. Although the smallness of these num- 
bers forbids the drawing of a rigorous conclusion from them, we must 
still be struck with such results. 

The seton, like the needles, cannot always be inserted between the 
broken ends ; this fact has given rise to another plan which merits 
serious attention. Oppenheim recommends in such cases the passing 
of two setons, one from one side and the other from the other side, 
close to the extremity of each fragment, and their withdrawal as 
soon as suppuration is established ; he has in this manner procured 
consolidation in the humerus, and also in the forearm. Saurer, in 
1833, passed a seton around a fracture of the tibia, in the following 
manner. He made an incision on the outer and one on the inner 
side of the bone: and from one to the other he passed, beneath the 
bone, a seton-needle half an inch wide and a little curved. There 
was considerable inflammation and suppuration; the seton was with- 
drawn on the tenth day; and three months afterwards the patient 
was able to resume his work in the field.f 

[In May, 1851, Dr. Peace passed a seton for ununited fracture of 
the femur, occurring in a laborer, at the Pennsylvania Hospital. 
The man had had syphilis; the fracture had occurred nine months 
previously. The seton was passed from before backward; it re- 

* Listen. Practical Surgery, third edition, 1840, p. 100; Norri3, loc. cit. 
f Xorris, loc. cit. 



252 A TREATISE ON FRACTURES. 

ma i nod in place three weeks, when the patient was attacked with 
pyaemiaj and died. The operation is not a favorite one in this 
country.] 

These results are calculated to excite the attention of surgeons. 
The object of the seton being to produce sufficient inflammation 
around the fragments, does not Oppenheim's plan more directly ac- 
complish this object than Physick's does? We shall resume this 
question directly. 

(4.) The Ligature. Between the seton and the ligature there is a 
good deal of similarity; the latter however is peculiar in being in- 
tended gradually to divide the fibrous tissue between the fragments. 

Somm£, of Antwerp, first conceived of this plan. He had occasion 
to treat an oblique fracture of the left femur, with overlapping of 
the fragments, the lower going inward and the upper outward. "The 
patient being laid on his back and firmly held, I thrust in," says this 
author, "a long trocar and canula, first below, at the inner side of 
the upper fragment, making it come out posteriorly a little to the 
outer side; the trocar was then withdrawn, and a silver wire carried 
through the canula as far as the posterior opening. The canula 
being now in its turn withdrawn, was readjusted over the trocar; 
the whole was again entered above and at the outer side of the lower 
fragment, and brought out at the same orifice posteriorly as before. 
The trocar being again removed, the anterior end of the silver wire 
was carried through the canula, so that both ends of the wire were 
together posteriorly, and a loop of it left in front. Then laying in 
one by an incision the two orifices made anteriorly by the trocar, and 
drawing on the two ends of the wire, I brought the loop between the 
fragments, and closed the incision through the skin by an agglutina- 
tive plaster." The limb was placed in a fracture-box, and at each 
dressing the ends of the wire were drawn upon, so as to bury the 
loop more deeply in the tissues. No bad symptoms occurred. The 
operation was performed August 12, 1828; six weeks afterwards, 
union was plainly perceived; the wire was however left in place till 
October 2. The apparatus was kept on till the middle of November; 
and the patient is even said to have recovered without any short- 
ening.* 

It was in fact a ligature also which Seerig used under the name of 
a seton, and this is the more clear from the circumstance that he 
used with it the serre-noeud. In his first patient the fracture was 
at about the middle of the tibia. Two longitudinal incisions two 
inches in length were made, one at each side of the tibia, parallel to 
it ; an S-shaped needle armed with a mesh of twelve threads, was then 
carried around the pseudarthrosis, first from behind forward and from 
within outward, afterwards from before backward and from without 

* Medico-Chir. Transactions, 1830, vol. xvi, p. 36. 



A TREATISE ON FRACTURES. 253 

inward; the two ends of the mesh were fastened by the serre-noeud 
of Graefe.* In the evening of the same day there came on violent 
fever, with swelling and severe pain in the limb. Suppuration was 
soon established ; the ligature, which was tightened anew every day, 
came away on the sixth; at the end of a month the external wounds 
had cicatrised, and in fifteen days more, union was complete. 

It should be said that the fracture in this case was of only four 
months' standing. In a fracture of the femur, two years old, the 
ligature failed, and resection was decided upon as the only proper 
resource, f 

(5.) Resection. — Invented by White, in 1760, this was first prac- 
tised in the following case. 

A boy, nine years old, had had the humerus fractured at its mid- 
dle, six months before ; amputation had been recommended. White 
proposed to make a longitudinal incision at about the external and 
lower margin of the deltoid, to turn out first one and then the other of 
the fragments, which would be easy from their mobility, and resect 
them with a saw or with cutting forceps ; and to treat the case subse- 
quently as one of compound fracture. The operation was performed 
by an expert surgeon; the patient did not lose a spoonful of blood; 
and the wound was nearly healed at the end of fifteen days, when 
erysipelas came on to delay the cure. However, six weeks after the 
operation, the callus began to form, and was soon ossified. 

In 1769, White had another case of pseudarthrosis to treat, this 
time affecting the tibia, with overlapping. The fibula being partly 
united, it was not possible to turn out the fragments as in the case of 
the humerus; the operation had therefore to be modified. White 
made a longitudinal incision about three and a half inches long, and 
exposed the end of the upper fragment, which was somewhat pointed, 
and covered with a white cartilaginoid mass, but showed no trace 
of callus ; by means of a very large trephine, he easily effected the 
resection. The lower fragment was now more exposed than before ; 
and as it could not be resected without much pain, difficulty and 
danger, White contented himself with scraping the periosteum cover- 
ing it ; he then filled the wound with dry charpie, and applied splints. 
The ensuing inflammation was but slight. The wound was kept di- 
lated either with sponge or with charpie. About the eighth day, 
White removed with cutting forceps a point of bone left by the tre- 
phine, and touched the lower end with butter of antimony. He 
likewise applied this caustic between the two fragments, so as to 

* [A metallic stem with an oblique perforation at one end ; through this are 
passed both ends of a thread, to be fastened to a screw which runs into the 
other end of the stem ; the bight or loop thus left at the extremity of the stem 
will of course be drawn in or let out as the screw is turned one way or the 
other.] 

f Archives GCnirales de Mddecine, Jan., 1839. 



254 A TREATISE ON FRACTURES. 

destroy the tissue preventing their immediate contact ; this operation 
was repeated three or four times at suitable intervals. There fol- 
lowed some slight exfoliation, after which the progress of the cure 
was uninterrupted. Nine weeks after the operation, the patient 
could walk with a stick; at the end of twelve weeks the wound was 
entirely cicatrised and the consolidation complete.* 

It will be observed that White did not leave much to be done by 
his successors. Resection of both fragments and of one alone, scrap- 
ing of the periosteum, cauterisation, each of these was tried by him 
successively. "Wardrop, in 1802, applied resection in the forearm; 
Rowland, in 1806, to a fracture of the femur, and both these cases 
were successful. We find a great many such attempts, but fortunate 
results are by no means equally frequent. In order to determine 
the proportion of the successes and failures, Norris has compared 
only thirty-eight cases, even including some of mere scraping of the 
bone. I have thrown out these cases ; and collecting all those men- 
tioned in Norris's memoir, have made up a total of sixty-two opera- 
tions, in which resection has been performed on one bone or on both 
fragments; they are as follows: 

27 fractures of the humerus 11 cures, 14 failures, 2 deaths. 

17 " " femur - - - - - 10 " 3 " 4 " 
9 " of one or both bones of forearm - 7 " 2 " " 
8 " of the leg or tibia alone - - - 8 " " " 
1 > " "jaw 1 " " " 

In the leg and forearm, the results seem as satisfactory as those 
from the use of the seton; in the humerus, the proportion of cures 
is nearly the same, but there are two deaths instead of one ; it is 
however in the femur especially that we begin to get at the truth of 
the matter. The cures cover more than half the cases; but the 
deaths comprise nearly a quarter; and we must remember besides, 
that these tables, derived from observations published here and there, 
would show but a very small proportion of the actual number of 
failures. 

On the whole, although sometimes successful, resection is always a 
serious operation, and one which in the thigh and forearm, where 
there is but a single bone, involves at least as much danger as an 
amputation would. All surgeons are agreed as to the difficulties sur- 
rounding it; in the thigh especially, we should read the reports of 
cases to obtain a correct idea of them. Rowland was obliged to 
make an incision seven inches long, and to cut across a great part of 
the vastus internus muscle. He states that the operation exceeds in 
difficulty all that he had ever seen or performed, and that he has 
doubts about recommending it to others. In a case reported by 
Vallct, it occupied an hour; and the patient died in convulsions on 

* White, Cases in Surgery, pp. 69 and 79. 



A TREATISE ON FRACTURES. 255 

the same day. In a patient operated on by Hewson, the time re- 
quired was still longer; according to Norris it was nearly two hours.* 
Even in the humerus, it is by no means always easy; and frequently 
after it is accomplished the surgeon encounters great difficulty in 
the coaptation of the ends of the bone. In a patient operated on 
by Boyer, they were separated by an interval of nearly two inches; 
and in order to bring them together the elbow had to be supported 
by a special apparatus. M. Flaubert has seen them not only sepa- 
rated by a wide interval, but also displaced laterally, the upper 
backward and outward, the lower inward and forward. This dif- 
ficulty has struck several operators ; and Boyer's bandage not being 
sufficiently certain in its effects, other means have been devised. 

In a young girl whose humerus he had resected, M. Boux inserted 
the point of one of the fragments in the medullary cavity of the 
other: no bad symptoms ensued; but unhappily, at the end of two 
months, a fall on the arm undid the whole of the treatment, and 
subsequently amputation became necessary. f A surgeon, whose 
name is not given, conceived the idea of making the fragments hold 
together by shaping their ends into a sort of mortise and tenon ; but 
the attempt failed, and the ends soon became loose again.J Lastly, 
Dr. Kearney Bodgers, [of New York,] in 1825, and subsequently 
M. Flaubert, of Bouen, resorted to a means the solidity of which 
cannot be questioned, viz., the suture of the fragments. 

Bodgers first tried it in a young man of fifteen, who had a fracture 
of the humerus of seven months' standing. The fragments being 
resected, and still not coming together, he made a hole near the 
extremity in each, penetrating into the medullary canal; then 
through both holes he passed a silver wire, bringing its two ends 
through a canula which he left lying in the wound. On the sixteenth 
day the canula came away, and with it the wire loop ; on the sixty- 
ninth day consolidation was complete. 

Mott, in 1831, obtained a similar result in the humerus; Cheese- 
man, in the humerus and femur; and afterwards Bodgers, in the 
radius. Their operations are described as above, but in the later 
trials the canula was dispensed with, the two ends of the wire being 
merely twisted together and left in the wound. § 

[Dr. N. B. Smith of Baltimore has twice done this operation suc- 
cessfully in the femur. In one case four gold wires were used, and 
the patient walked to Dr. S.'s office to have the last one removed.] 

* Tallet, Tlilse inaug., Strasbourg, 1817, (quoted by Yelpeau ;) Kirkbride, 
Repoiis office cases of ununited fracture, Amer. Journal of the Med. Sciences, 
Nov.. 1835. This paper was partially translated in the Archiv. G6n. de M6de- 
cine for Feb., 1836. 

t A. Berard. op. cit., p. 53. 

% Laloy. De la suture des os, etc , T7ie.se inaug., Paris, 1839. 

\ J. Heard, Report of Cases of Ununited Fracture, New York Journal of 
Medicine and Surgery, Oct. 1839. 



A TREATISE ON FRACTURES. 

M. Flaubert's operation, dating back only to 1838, was done in a 
manner somewhat different. The resection being accomplished, the 
Burgeon bored with a gimlet the external face of each fragment at 
about one-eighth of an inch from its extremity, the gimlet being di- 
reeted obliquely toward this extremity; then with an ordinary needle, 
a simple thread was passed through both holes, and by means of this 
there was drawn through a more solid ligature composed of four 
strands of waxed thread; this latter, tightened and knotted in the 
usual manner, insured a very exact apposition. The subsequent 
course of this case was in no way peculiar ; on the twentieth day the 
ligature came away, bringing with it a small lamella of necrosed 
bone; consolidation however did not occur, and the patient was 
obliged afterwards to wear a leather brace to give solidity to the 
arm.* 

M. Flaubert has since imagined that the chances of success would 
be increased by sawing each fragment obliquely, so as to make them 
correspond by a larger amount of surface ; an idea which might be 
tested, not only with the suture but also with the ligature. 

I do not think there is much difference between the resection of 
both fragments and that of one alone; the consequences are the 
same, and it is to be remarked that from White to Dupuytren, it was 
the difficulty or impossibility of resecting the second fragment, which 
has limited the operation to the first. Dupuytren's principle on this 
point is no more peculiar than his operation. 

(6.) The rubbing together of the broken ends was at first merely 
an expedient of White's, as a substitute for the resection of the 
second fragment. Some surgeons would make of this a separate 
plan, rubbing the ends together in place of excising them. It is a 
kind of incomplete resection, which doubtless makes the operative 
procedure an easier one, but which seems not much less dangerous 
than resection properly so called. White, of New York, resorted to 
it in 1816, for a fracture of the tibia two years old; he obtained 
union at the end of three months. Vincent, of London, tried it in 
a fracture of the forearm ; his patient died on the fifth day. Brodie, 
in 1835, practised it for a fracture of the leg in a boy five years old; 
he failed. To these attempts must be added that of Viricel, who 
passed a seton through a pseudarthrosis of the femur, having previ- 
ously filed up with a coarse file the opposing surfaces ; the patient 
died some days afterwards. f 

John Hunter, starting with the erroneous idea that there was gene- 

* Laloy, op. cit. 

t Noma, loc. cit.; Monfalcon, Mtm. sur Vitat actuel de la chirurg., 1816, p. 
195. J.arthelemy (Thdse inaug., Montpellier, 1814, p. 21,) also proposed what 
he called scarification of the fragments, by carrying to the bottom of an incision 
in the Bofl parts a silver canula, bearing a sort of rasp ; I do not know that this 
was ever actually put in practice. 



A TREATISE ON FRACTURES. 257 

rally in pseudarthrosis a synovial cavity, asserted that it was enough 
merely to lay open this cavity and irritate the surfaces. Sir E. Home 
quoted in his lectures a case of ununited fracture of the humerus, 
thus treated by Hunter. There was a false joint ; Hunter opened 
it, and introduced a spatula so as to irritate the entire surface. There 
followed a good deal of inflammation, which resulted in the soldering 
up of the false joint.* Here, indeed, there was a sort of moderated 
friction, only applicable in some exceptional cases. 

An idea at first sight irore attractive was to perform this abrasion 
with the advantages of the subcutaneous method. "In one case," 
says Sir C. Bell, " I thought myself warranted, from observations 
made on animals, in proposing to pass a sharp instrument obliquely 
in as far as the bone, to penetrate the ends of the fragments. I 
thought that the wound by which the instrument had entered would 
soon heal, and at all events that the ends of the bones would be 
enough irritated to resemble a simple fracture much more nearly than 
is possible after resection. But perhaps the patient judged more 
correctly than the surgeon; he would not submit to have it done." 
Something similar was recently attempted in Paris by M. Blandin ; 
but the result did not meet his expectations. 

The patient was a waiter, forty-three years old, healthy, but having 
had for eighteen months a very oblique fracture at the lower part of 
the humerus. A fold of the skin on the outer side of the arm being 
raised up, a narrow bistoury was carried through this fold, down to 
the bone. Another narrow bistoury, but button-pointed, was now 
substituted for the first, and carried carefully into the space between 
the fragments ; it was then made to divide the intermediate fibrous 
tissue, while the operator guarded the brachial artery with his left 
forefinger. The fibrous layer being divided, the surgeon, turning 
the edge of the bistoury in various directions against the surfaces of 
the fragments, rubbed and scraped them as much as possible ; after 
which the puncture, which had bled but a few drops, was closed with 
a bit of lead-plaster, and the arm dressed with splints and bandages. 
But on the same day there was felt severe pain in the arm ; two or three 
days afterwards an attack of erysipelas came on ; the puncture ulcer- 
ated and discharged bloody pus ; the opening had to be enlarged, 
and a second one made on the inner side.f 

Might we not, however, hope, by keeping the limb entirely mo- 
tionless, to avoid any suppuration ? It would seem that Biondi, of 
Bucharest, actually did succeed, by means of the subcutaneous sec- 
tion, in curing a pseudarthrosis ; but I have not read his observations, 
and cannot state the precise circumstances of his good fortune.J 

* Hunter's Compute Works, translated into French, tome i, p. 561 ; London 
Med. Gazette, vol. iii. p. 56. 

t Gazette des Hopdaux, 1844, pp. 557 and 569. 
+ Gazette des Hopitaux, 1845, p. 64. 

17 



258 A TREATISE ON FRACTURES. 

(7.) Lastly, the cauterisation of the fragments, another of White's 
expedients, has heen elevated to the dignity of a method. Accord- 
ing t<» Norris, it was first tried by Mr. H. Cline, of London, and with 
Buccess. Earle, in 1821, repeated this course on two patients with 
pseudarthroses of the humerus ; after laying bare the fragments by 
a long incision exteriorly, he cut through the intermediate fibrous 
tissue, scratched the ends with the bistoury, and then rubbed them 
with a stick of caustic potassa until they assumed a black color. He 
failed in both cases. It appears, however, that both Hewson and 
Barton succeeded with it in fractures of the leg ; Norris himself ob- 
tained by means of potassa the consolidation of a humerus fractured 
four years before. Others have been equally successful with other 
caustics ; thus Lehmann and Weilinger used the butter of antimony, 
before preferred by White ; Ollenroth employed nitric acid, etc.* 

After such cauterisations, as might be expected, we should rightly 
judge exfoliation to be unavoidable. In Earle's first case, two little 
bits of bone were six weeks in becoming detached ; but in the second 
there were none. Hence it appears that cauterisation does not in- 
volve such serious dangers as resection or mere rubbing; but the 
published cases are too few to enable us to pronounce positively on 
this point. 

There remains one other resource, allied to cauterisation ; it is a 
cauterisation very much mitigated in severity, and also subcutaneous. 
It is due to M. Mayor. 

A young man of twenty-eight had had for six months an ununited 
oblique fracture of the femur. M. Mayor tried at first rubbing, and 
also powerful momentary pressure with a tourniquet. This caused con- 
siderable swelling around the fragments ; but at the end of ten weeks 
the callus was no more advanced than on the first day. The surgeon 
then luxated, to use his own word, the joint, so as to slide between 
the fragments the canula of a very large trocar. Through this me- 
tallic canal, which he left in place for eight hours, he passed at dif- 
ferent times a rounded iron which had been previously dipped in 
boiling water. He thus excited severe phlegmonous inflammation; 
a free exit had to be made for the pus ; but at last, in less than three 
months, the patient could use his limb, and walk with a stick. 
M. Mayor claims to have since been even more successful in another 
case. 

[In November, 18-48, Dieffenbach published in Casper s Wochen- 
sc7irift an account of a new plan for exciting inflammation and pro- 
moting the union of fractures, viz., the introduction of ivory pegs 
into holes previously drilled in the bone. This method was success- 
fully employed by him in a good many cases ; in the United States 
it has been occasionally practised. 

* Earle, 3fedico-Chir. Transactions, vol. xii, p. 190, and Mel de chirurgie 
ttrangere, tome i ; A. Berard, loc. cit. ; Norris, loc. cit. 



A TREATISE OX FRACTURES. 259 

I have seen the mere boring of the bones tried in one case, but 
the result -was negative.] 

After this lengthy exposition of methods and processes, we must 
endeavor to make a well-founded selection, and this is assuredly by 
no means easy. A comparison of the results obtained sheds light 
on one side of the question ; perhaps the study of nature's occasional 
processes will tend to still further clear it up. The observations here 
are rare ; we however see the work of consolidation recommenced in 
two ways. First, from the effect of accidental contusion. A sailor 
having broken his humerus, the bone showed no tendency to unite 
for three weeks; but the patient then getting a fall and severely 
bruising the arm. from that time his recovery was rapid.* Ames- 
bury saw a much more remarkable case. A fracture of the femur 
remained movable for several months ; the patient was thrown from 
his cabriolet, and the wheel went over his thigh just at the seat of the 
false joint. Active inflammation ensued, confining him to his bed, 
and bringing on the union of the broken bone. 

The second process is a spontaneous inflammation of the limb. 
Thus erysipelas, which may destroy the commencing callus, would 
appear sometimes to revive the action when it languishes. Seerig 
gives a very curious instance of this. A compound fracture of the 
humerus just above the condyles remained ununited, and the patient 
was unwilling to submit to any treatment for it. He was all at once 
attacked, without any apparent cause, with erysipelas of the limb ; 
and this brought on consolidation. 

From this small number of cases, we see that it is an irritation of 
the soft parts, and not of the bony fragments, which sets up a favor- 
able action. In ordinary normal callus, whence come the materials? 
From the soft parts. Why, then, attack the broken ends, resect, 
scrape, and cauterise them ? Excepting resection, for which there 
are special indications to be presently pointed out, such operations 
are really irrational: they have, indeed, sometimes succeeded, because 
the bones could not be so disturbed without inducing active inflam- 
mation of the soft parts; but this is buying too dearly a result which 
may be obtained at a less cost. 

I think, therefore, it is upon the soft parts that we ought really 
to work ; and following the example of nature, we should first of all 
excite in them the adhesive inflammation. Stimulating lotions have 
too slight, vesication too powerful an action ; but sinapisms, produc- 
ing an irritation at once more prompt, more intense and more pro- 
found, without the disadvantage of involving suppuration, appear to 
me to answer a far better purpose. The rubbing of the fragments 
together acts only by irritating the soft parts; and with the same 
object we may use also rude and forcible flexions of the fragments 

* Wardrop, loc. cit. 



2GU A TREATISE ON FRACTURES. 

upon one another, in order to break the connecting fibrous tissue; or 
a direct and sudden compression, violent enough to contuse the sur- 
rounding tissues. Lastly, acupuncture affords us a safe resource, 
the efficacy of which may be increased by passing electrical currents 
through the needles. 

Thus, we try first to excite adhesive inflammation; when all our 
means for inducing this have failed, and then only, we resort to sup- 
puration. Here there occurs a question: should we, as some adhe- 
rents of the seton do, keep it up for whole months, or should we, 
following Liston's example, withdraw the seton after eight or ten 
days ': To prescribe the long continuance of the seton as the general 
rule, is actually an absurdity. What is it which retards and interferes 
with consolidation in compound fractures, if not prolonged suppura- 
tion? But on the other hand the term fixed by Liston is too arbi- 
trary; the true rule is to retain the seton or keep up the suppuration 
just until it has induced the proper degree of engorgement of the 
soft parts. Eight days may suffice, in some cases; in others fifteen, 
twenty, or even more, will be necessary. The study of the facts has 
led us to the same results, and we have seen the seton fail from too 
early removal as well as from too long continuance. 

A second question, quite as important, is whether or no we must 
establish suppuration between the broken ends, at the very seat of 
the fracture. Theoretically I see neither necessity nor utility in so 
doing; and experience has decided the question in the same way, 
as was proved by Oppenheim. We should add that the seton carried 
between the fragments, reducing the lesion to the state of the severest 
form of compound fracture, involves nearly as much danger as re- 
section, and exposes to the same accidents. I will go further ; it is 
a very severe mode of inducing suppuration around a pseudarthrosis, 
to pierce the part through and through twice with a seton ; M. Mayor's 
cauterisation, attacking the false joint on one side only, will often 
suffice, and has already received the seal of experience. I believe 
however that this process could be advantageously simplified, and 
that it would suffice to make an incision down to the bone, and cau- 
terise it to the bottom with potassa, so as to prevent its healing too 
readily. 

Lastly, in some cases of overlapping of the fragments, and espe- 
cially when they are loose among the tissues, resection has seemed 
to me to be the only rational resource, combined with suturing the 
fragments, which I consider a real step in advance. I have seen 
three ununited fractures of the femur, of very long standing, which 
I did not then think of treating, so great was the mobility; having 
the suture, I should not now hesitate. For the rest, we should not 
forget that in all operations which expose the fragments, but espe- 
cially after resection, we have to dread repeated attacks of erysipe- 
las. White's first patient had but one; Kirkbride saw them in all 



A TREATISE ON FRACTURES. 261 

the cases which he reports, except in one ; and in this one it was 
doubtless for want of time, the patient dying on the sixteenth day. 
To cite one of the most striking instances, a young man of twenty- 
six, in whom Harris successfully resected the femur, had erysipelas 
no less than eight or nine times. 

[From the case-books of the New York Hospital, I have obtained 
the following memoranda of nine cases of non-union, treated in that 
institution : 

No. 1. A man, aged 30. Left humerus broken eight months be- 
fore. Drilling, rubbing and close contact had been tried. Acupunc- 
ture with electricity proved effectual in inducing firm union. 

No. 2. A man, aged 24. Left humerus broken four months before. 
Resection, drilling, a silver wire kept in place for five weeks, and a 
starched bandage, gave very little relief. He was sent into the 
country. 

No. 3. A little girl. Humerus ununited at the end of four months. 
The fracture was cut down upon, and a bit of muscle cut away from 
between the broken ends ; lower fragment scraped, and three-quar- 
ters of an inch of upper one removed; a silver wire introduced, and 
kept in for thirteen days. Some relief. 

No. 4. A man, aged 36. Right humerus broken eight years be- 
fore; no union, but some use of the arm by keeping it supported 
with a leather splint. 

No. 5. A man, age unknown, whose right humerus had been broken 
fifteen years before. Rubbing of the ends, and the seton, had been 
tried without success ; resection was performed, and complete union 
obtained, although with a shortening of two inches. 

No. 6. A man, aged 26. Right radius broken four months and 
ten days before. Rest and proper position had been tried in vain; 
resection was performed, and the ends became firmly united. 

No. 7. A man, aged 28. Right femur broken nine months before. 
Resection, and complete consolidation. 

No. 8. A man, aged 28. Left femur broken three months before. 
Rubbing of the ends, Amesbury's splints, exercise, mercury, and the 
seton having failed, amputation was performed. 

No. 9. A man, aged 60. Left femur broken seven months before. 
Friction, splints, and the immovable apparatus, had no effect. Am- 
putation ; fracture oblique, united by ligament. 

For a report of thirteen other cases of pseudarthrosis, treated in 
various ways, see a paper by John "Watson, M.D., of New York, in 
the New York Medical Times, vol. i, No. 1, Oct. 1851.] 

§ XV. — Of Secondary or Recurring Fractures. 

Although the immobility of the fragments, the absence of pain at 
the seat of fracture, and the return of the limb to its functions, 



262 A TREATISE ON FRACTURES. 



afford onmistakable evidence of consolidation, still, especially for 
some time, the patient must be very careful; we have seen, in study- 
ing the transformations of the callus, that the most compact diaphyses 
arc hardly ever reunited except by spongy tissue, which is of course 
»lid than that of the rest of the shaft. Sometimes a sudden 
effort, or the mere weight of the body, is sufficient in fractures of 
the lower extremity to bend even an old callus; while a direct blow, 
or a fall, instead of bending may break it. 

M. Jacquemin had an opportunity of experimenting with these 
two processes upon two specimens of callus of a known date. A 
man, aged 51, had been suddenly carried off by a double pleuro- 
pneumonia, on the forty-fifth day of a fracture of the thigh. The 
femur was stripped of the soft parts, and fixed horizontally on a 
table, so that the callus and the longer fragment projected over the 
edge; there was then hung at the outer end a scale-pan, in which 
weights were put and gradually increased. At twenty-eight kilo- 
grammes, [seventy pounds avoirdupois,] the callus bent and curved 
without any apparent rupture; at thirty, the fragments separated, 
the callus remaining nearly entire, and attached to the upper portion. 
An oblique fracture of the humerus at fifty-nine days, similarly 
treated, first bent and then broke with a weight of less than twenty- 
eight kilogrammes.* 

It is by no means extremely rare to meet with such curvatures in 
the living subject. Wall has given an account of a carpenter forty- 
eight years old, who had had an apparatus on for fifty-four days for 
a simple fracture of the leg; eight days after its removal, contrary 
to the surgeon's advice, he resumed his occupation; but in the course 
of fifteen days the bones became so curved as to shorten the leg three- 
quarters of an inch. Oesterlen saw a young man of nineteen, cured 
in two months of a fracture of the femur, who was passing at the 
end of the third month along a slippery place, when he slipped, and 
felt severe pain, and crepitation, at the seat of fracture ; he did not 
fall, but walked with assistance some twenty steps ; the femur was 
curved outward, but not entirely broken. I have now in my wards 
a young man of twenty four, who at the fifty-fourth day of a frac- 
ture of the femur, trying to walk, bent the callus so that the two 
fragments present a very marked angle anteriorly. But the most 
remarkable ease of this kind is that of M. Guillon, who has seen the 
femur at the one hundred and thirty-fifth day of a simple fracture, 
in a young girl of sixteen, suddenly bent to an angle in the effort to 
avoid a fall ; it was really a mere curvature, since the patient could 
still walk on the limb for two days. 

In these different cases, we really cannot tell to what should be 
ascribed this unusual flexibility of the callus; sometimes its cause is 

* Jacquemin, Thhse inaug., Paris, 1822, p. 14. 






A TREATISE OX FRACTURES. 263 

more evident, as in the following case. A man of forty-eight had a 
fracture of the leg, consolidated in eight weeks in spite of a small 
abscess ; he attended freely to his affairs, when at the middle of the 
eleventh week the abscess reopened, and both bones bent at the 
callus.* 

Complete rupture of the callus may occur quite as soon after the 
original fracture, but from somewhat different causes, as was before 
mentioned. We find in Delamotte two cases of fracture of the leg, 
which at about the fiftieth day were reproduced by the patients foil- 
ing while walking with crutches. The same author has likewise seen 
such ruptures occur much later; for instance, one of the patients just 
mentioned had been more than three months cured of his second 
fracture, when he was thrown from his horse, and broke his leg again 
at the same place. In another case, a young lady, who had been 
cured two months of a broken leg, fell down stairs and reproduced 
the fracture. f 

Oesterlen has collected ten cases, some of which are exactly simi- 
lar to those of Delamotte; but the others are still more curious, as 
showing by experiment what pathological anatomy would enable us 
to foresee, viz., that months and years may elapse without the callus 
acquiring the same solidity as the rest of the bone. A man of 
thirty, eight months after a fracture of the forearm, broke the callus 
by striking the edge of a table; a child two and a half years old 
refractured the clavicle after eighteen months; in two other children 
of from fourteen months to two years, the femur was refractured by 
falls after three years; and to show that these late recurrences are 
not confined to children, a man of thirty, who two years before had 
had his leg broken and cured with a great curvature outward, broke 
it again at the same spot.J 

[In the Medical Neivs for July, 1857, there is mentioned a patient 
at St. Bartholomew's who has fractured each thigh three times — 
always by accident, and always at the same place ; each time reco- 
vering well and with a useful limb. 

Jane Savage, aged 28, a domestic servant, was admitted into the 
Pennsylvania Hospital, June 1, 1853, having tripped in walking, 
and fractured the left femur two inches above the condyles. For a 
few days there was much swelling and irritation ; she was discharged 
with a useful limb, September 1. She was readmitted March 31, 1854, 
having pgain tripped in walking, with the same result. A tumor now 
formed about the seat of fracture, gradually increasing till it attained 
an enormous size, and discharging a thin fluid from one or two open- 
ings. The shortening became extreme, the tumor kept involving the 

* Oesterlen. SfU/r la rupture du col, translated into French by Maurer, obs. 31, 
33 and 35 ; Guillon. Th£se mcnig., Paris, L820, p. 14. 
t Delamotte. TrqiU comp. de chtr., obs. 371 to 373. 

i Oesterlen. op. ciL, obs. 2\ 



264 A TREATISE ON FRACTURES. 

bone higher and higher, and amputation was advised. This she would 
not submit to, and death ensued from exhaustion, July 14, 1855. 
The tumor was partly cartilaginous and partly bony. 

Margaret Newland, aged 87, was admitted into the same institu- 
tion, August 14, 1853, with a fracture of the right femur at about the 
junction of the middle and upper third, caused by a boy tripping her 
up. She had had the same femur broken at the same place twice 
before. She was discharged by request, after being under treatment 
eighty-five days; the limb was not yet consolidated.] 

It should be added that these latter cases are very rare, and in 
studying them in detail we see that in all of them there had been 
union with angular deformity or with notable overlapping. I have 
myself had to treat a young girl of twenty-one who had, by a fall, 
broken the femur at the exact spot where it had been broken six or 
seven years before ; the fracture was in the upper third of the bone, 
and had united previously with a very considerable angle, salient ex- 
ternally. Perhaps under these circumstances yielding is more to be 
dreaded in children; and we shall hereafter be confirmed in this idea 
by some facts concerning artificial fracture. I would, however, call 
to mind here the two children cured of fractures of the femur, in 
whom the fractures were repeated at different parts of the bones, (see 
page 31 ;) in fact the consolidation was regularly accomplished, but 
the subjects were rachitic. 

On the whole, these facts should show how carefully convalescence 
from fractures is to be watched, even when the callus is ossified and 
apparently solid, and especially if union has occurred at an angle or 
with overlapping. The prognosis of secondary fractures is, more- 
over, not very serious ; Delamotte has observed that they are neither 
so troublesome nor so tedious to cure as the primary ; a fact which 
he explains by the spongy nature of the fractured callus. They are 
to be treated precisely as if primary. Thus for a bending of the 
callus which occurred in a young man of nineteen, which might very 
well be likened to an incomplete fracture of a child's bone, Oesterlen 
had steady, gentle pressure made with the hand over the salient angle, 
for several hours, and succeeded in bringing the bone to its 'right 
direction. M. Guillon' preferred making gentler pressure for his 
patient, by means of an apparatus to be hereafter described. In 
case of complete rupture, reduction should be performed as usual, 
unless the previous deformity of the callus will not permit us to give 
the fragments their normal direction, obliging us to make use of spe- 
cial means. Then, moreover, the rupture is a fortunate occurrence 
for the patient, since it enables us to correct the angular deformity 
or overlapping; such was the case in several of the instances whose 
history is given by Oesterlen; nature performing an operation some- 
times judged necessary by the surgeon, and one which will presently 
engage our attention. 



A TREATISE ON FRACTURES. 265 



§ XVI. — Of Deformed Callus, and its Treatment. 

This is one of those difficult subjects on which surgeons are greatly 
at variance, that practice which some consider rational being formally 
disapproved of by others. Those deformities of the callus which 
may require treatment are of three kinds, clearly set forth by Cel- 
sus : (1) the fragments are joined at an angle or with overlapping, 
whence arises notable shortening and disfigurement; (2) two bones 
are fused together, as in the forearm ; (3) the sharp point of a frag- 
ment, buried in the soft parts, keeps up a continual irritation in 
them. 

In all these cases, according to Celsus, we must repeat the frac- 
ture, and put the fragments in better position. For this purpose, 
after using fomentations with hot water, and frictions with oil, he 
caused the limb to be extended, breaking up the callus, if it was yet 
tender enough, with his hands ; if this manoeuvre failed, he contented 
himself with compressing the projection of the callus by means of a 
wide splint (regula) wrapped in cloth, so as gradually to bring the 
fragments into place. 

Galen likewise advises the reproduction of the fracture when it is 
still recent.* Paulus iEgineta goes further. He not only attacks 
the newly-formed callus, which has not yet taken root, but when it is 
entirely solid like stone, he would cut through the skin, and then di- 
vide it with cutting forceps. He seems, in extolling this plan, to 
find fault with another which consisted in breaking up the callus 
without any previous incision; so that at that period there would seem 
to have been known three principal methods of treatment : the cor- 
rection of the callus before it became solid ; its rupture, and its sec- 
tion, after it had ossified. A fourth, and much more recent method, 
is resection. 

First Method; Correction of the Callus before Consolidation. — 
This method comprises two modifications, according as the reduction 
is made at one effort, by means of extension and vigorous coaptation, 
or more slowly by means of compression. 

The sudden reduction is not much more than an application of the 
precept of Hippocrates, to remove the apparatus for the purpose of 
ascertaining or correcting the coaptation, after about two-thirds of 
the time necessary for consolidation had elapsed. This is the usual 
rule ; but what has been said concerning the hindrances of consoli- 
dation may show that one may have reduction to perform even after 
several months ; of which I have mentioned instances. Now if we 
read over carefully most of the observations of so-called vices of the 
callus corrected by extension and pressure with the hands, it will be 
seen that they come under one or the other of these two categories. 

* Galen, Ars medicinalis, cap. xciii. 



266 A TREATISE ON FRACTURES. 

Dnpnytren's Legons de clinique contain ten cases of this kind of 
reduction': one is a fracture of the metacarpus, twenty days old; 
seven are fractures of the lower end of the radius, twenty to thirty- 
five days old ; one a fracture of the tibia of three months and a half; 
and lastly there is one fracture at the middle of the forearm, of four 
months 1 standing; but these two last were not consolidated. The 
cases collected by Oesterlen afford perhaps still more instruction. 
Two were fractures of the leg, of forty-three and of eighty-four 
days' standing, in adults; these evidently were not consolidated. 
But in the six others, which were all fractures of the femur, of four, 
five, seven, and nine weeks' standing, most generally the attempts at 
reduction elicited an unequivocal crepitation, showing ossification to 
be at least quite advanced ; it is remarkable that the subjects were 
all children, the youngest four and the oldest twelve and fourteen 
years old.* We have already noticed the greater frequency of acci- 
dental refractures in early life. It might be said that in children the 
callus, although more ready to ossify, is at the same time more easily 
broken, either because it shares the softness of the entire bony sys- 
tem, or because its less volume causes it to yield to slighter force. 
Three of the fractures of the radius reduced by Dupuytren after 
twenty-nine, thirty, and thirty-two days, were in children of ten to 
fifteen years old. M. A. Thierry says that he has often seen his 
father break with his hands the deformed callus in children, at the 
end of ten, twenty, or thirty days. He adds, however, that in all 
these cases the fractured limbs still retained some degree of mobility.f 
The operative procedure is nearly always the same. If extension 
with the hands of assistants does not suffice, we resort to loops. De- 
lamotte, in a case of fractured femur of nine weeks' standing, re- 
quired only two assistants, using loops. Rapp, in a case quoted by 
Oesterlen, had extension made by four men ; Dupuytren himself 
once thought proper to make counter-extension with a loop attached 
to a fixed point, and extension with another loop. Guy de Chauliac 
saw extension successfully made with weights ; Fabricius of Acqua- 
pendente obtained a favorable result in a fracture of the leg, with a 
machine like the bench of Hippocrates, in which extension was made ' 
with a windlass. I think that pulleys give us at the same time greater 
safety and greater force, and would call to mind that they were suc- 
cessfully employed by Derrecagaix in a nearly analogous case, (see 
page 247.) While traction is made, the surgeon should press with 
both thumbs so as to efface the salient angle, or, if necessary, to break 
the callus; if this pressure is insufficient, an assistant should be 
called in. Guy de Chauliac recommends the employment of the 
knee ; M. A. Thierry relates that his grandfather used his knee and 

* Oesterlen, op. cit., obs. 1 to 8. 

t A. Thierry, Du redressement des os fractures ; Experience, Nov. 4, 1841. 



A TREATISE ON FRACTURES. 267 

his hands at once, in renewing a six-months' old fracture of the femur, 
which, however, was not entirely consolidated. Lastly, we must not 
expect always to complete reduction on the first trial ; if we do not, 
we should either repeat our efforts after a few days, submit the limb 
to permanent extension gradually increased, or resort to compression. 

Compression may be made with splints merely, or with more com- 
plicated apparatus. The splints may be applied in three ways; 
sometimes the principal one acts directly on the projection of the 
fragments, as advised by Celsus; thus in a child four years old, 
with a fracture of the femur at the seventieth day, the convexity 
being anterior, Dupuytren first had the limb extended, and then put 
a splint on the front of the thigh, so as to compress without wound- 
ing the salient portion. Sometimes the splint is firmly fastened to 
the upper fragment, so as below to be widely separated from the 
lower one, which we then attempt to press toward it by bandages; 
in this way Dupuytren, having to treat a fracture of the leg twenty- 
nine days old, with an angle internally and the foot carried strongly 
outward, applied a strong inside splint, bringing the foot over to it 
by means of turns of a roller gradually tightened. Lastly, the splint 
may be placed on the other side from the angle ; a pad being then 
laid over the projection, a cravat or band is made to surround both 
pad and splint, tending thus to bring them together. Dupuytren 
gives us an instance of this also ; a man aged 44 had had for fifty- 
nine days an oblique fracture of the tibia with an anterior projec- 
tion ; there was placed under the limb a large cushion so arranged 
that its thinnest part corresponded to the ham and the thickest to 
the heel ; a splint was put on over this cushion, and a small pad over 
the angle in front, and then the whole was bound together with a 
roller, so as at once to push the upper fragment backward and the 
lower one forward. This apparatus was kept on for twenty-eight 
days, at the end of which time the limb had regained its natural con- 
formation. Desgranges of Lyons obtained, by a similar plan, a very 
satisfactory improvement in a fracture of the leg which had united 
with a marked angle externally, and which, it is curious, was of more 
than four months' standing. 

I have given these cases as examples of the method pursued ; but, 
in the leg especially, I am amazed that none of these accounts make 
any mention of pain, excoriation, or sloughing, especially when, as 
in some of Dupuytren' s patients, compression has been kept up 
twenty-eight and forty days. Practitioners must not expect to find 
it always so harmless; and I shall speak, in connection with oblique 
fractures of the leg, of the apparatus which I have had to employ, 
not indeed to correct the improper direction of old fractures, but 
merely to keep recent ones in the right position. 

Simple splints are, moreover, too liable to slip from side to side, 
and simple bandages too apt to become relaxed. Fabricius of Acqua- 



2G8 A TREATISE ON FRACTURES. 

pendente was the first, as far as I know, who used a special appa- 
ratus iu such eases. A young servant-man had an old fracture of 
the leg united at an angle, so that the foot was everted. Rupture 
of the callus was at first thought necessary; but the father objecting to 
this. Fabricius attempted bringing it gradually into position by means 
of certain instruments and plates of iron, which he has unfortunately 
omitted to describe. He was successful; but he carefully adds that 
such a result could not have been attained in an adult. 

Fabricius Hildanus had an outward curvature of the femur to 
treat in a child of eight years, the fracture dating back only eigh- 
teen days. He had a trough made of wrought-iron, to embrace the 
thigh externally, especially opposite the seat of fracture ; it reached 
from a little above the trochanter down as far as the ham. This 
trough was carefully padded wilh fustian; two bands of the same, 
fastened above and below the knee, held it firmly to the lower frag- 
ment of the femur; it was now of course widely separated from the 
upper fragment, and a band, likewise of fustian, was buckled around 
the pelvis in order to bring them together. By tightening up this 
latter band two or three times daily, the projection of the fragments 
was entirely corrected in three or four days. I have used a similar 
trough, but made of wood, fastened with leather straps, and the 
parts guarded with wadding and compresses, to bring into place the 
two fragments in the refracture of the femur already mentioned. 

Lastly, still more powerful means have sometimes been employed. 
In 1789, Desgranges of Lyons had to treat a fractured thigh in a 
boy of twelve; the patient was very intractable, constantly derang- 
ing his splints, and at the end of two months and a half the frag- 
ments presented a considerable angle outwardly. Desgranges had a 
machine made analogous to the compressor of Scultetus for the 
radial artery, consisting of three iron splints connected above and 
below by circular bands of the same metal, thus solidly embracing 
the limb. One of these splints was perforated so that a screw could 
be worked in it, carrying a pad to press on the projecting angle, on 
the principle of the tourniquet. This pressure was increased daily, 
while steady extension was kept up. At the end of three weeks, the 
improvement was so great that extension alone was sufficient; three 
weeks later, the consolidation was complete and regular, and the 
child subsequently became a soldier.* 

M. Guillon employed, in 1828, an analogous machine to correct 
accidental curvature in a fracture of the femur, the callus having 
bent after four months and a half. (See ante, page 264.) Continuous 
extension was effected by means of an apparatus with two splints; 
the outer splint, which was very thick, and fastened to the pelvis by 
a buckled girth, was traversed by the screw of a tourniquet, having 

* Jacquemin, op. cit., obs. 4 ; Sculteti, Armam., tabul. xxi, fig. 4. 



A TREATISE ON FRACTURES. 269 

at its extremity an oval pad five inches long and four wide, hollowed 
to adapt it to the shape of the thigh. The compression was kept up 
for twenty-two days, after which extension alone was continued for 
twenty-four days; and on the sixtieth day after the bending of the 
callus, it had acquired its proper shape, and firmness enough for the 
patient to walk with crutches. 

Again, in a young man of twenty-five, having a very much deformed 
fracture of the radius of forty-five days' standing, M. A. Thierry em- 
ployed a hand- vice in bringing it into shape; pressing gradually for 
one hour upon the fragments, the limb being wrapped in flannel and 
cotton. The first attempt having failed, another was made three 
days afterwards, with complete success. 

A question of importance in connection with this first method, is 
whether science has supplied any means of softening the callus, 
so that it may yield more readily. We have seen that Celsus re- 
commended fomentations with hot water, and frictions with oil; 
others have extolled baths, douches, poultices, plasters of all kinds; 
and Desgranges employed, on one of his patients, the inunction of 
bear's-grease. Neither theory nor experience will warrant our 
ascribing any efficacy to such means; poultices or baths may dissi- 
pate any remaining engorgement around the callus, but cannot act 
directly upon this. In none of the cases reported by Oesterlen was 
any preparatory treatment resorted to ; Dupuytren gave it no more 
consideration ; and in one case only, where he wished to make very 
powerful extension, the patient being young and vigorous, he ordered 
a bleeding and a bath, as he would have done in a case of luxation. 
Therefore, the correction of the callus being decided upon, it should be 
done as soon as possible ; and except in cases where there exists in- 
flammation or engorgement, the so-called preparatory treatment only 
makes us lose precious time. 

Second Method; Rupture of the Callus. — This method also is 
variously modified, according as we operate by percussion, by sudden 
and forcible, or by gradual and moderate pressure. 

Percussion would seem to have been in use in Asia among the co- 
temporaries of Rhazes; but he does not say how it was performed, 
nor does he mention it except with disapprobation. Fabricius of 
Acquapendente speaks of a process which consisted in breaking 
the bone with a hammer, the part being so wrapped up in cloths or 
sponges as to break the force of the blows. But, like Rhazes, he 
condemns the plan, because of the danger of breaking the bone at 
some other point than at the callus. 

Rude and forcible pressure was made by placing a stick across the 
limb, and then bearing down strongly on its two ends. Fabricius 
of Acquapendente, who first mentions this, rejects it for the double 
reason that it may break the bone at some other point, and that it 
may cause too much contusion of the soft parts. Oesterlen tried 



270 A TREATISE ON FRACTURES. 

something similar, but as an experiment merely, upon the humerus 
of an old woman whose death occurred eight weeks after her fracture. 
The hone being placed transversely over two sticks, the experimenter 
bore Btrongly upon the middle of the callus with another stick which 
he held in both hands; the callus broke under this force; but we 
should consider that it was of only recent date, and also that the 
soft parts bad been removed. Pressure with the thumbs and knee 
would certainly be safer, but it is doubtful whether it would be suf- 
ficient to break a well-consolidated callus. 

Moderate and graduated pressure requires the employment of a 
Screw acting directly on the bone, like a tourniquet. Purmann would 
seem to have been the first to recommend a screw; but his advice 
and his machine were both forgotten, when in 1782 Bosch, studying 
surgery in Augsburg, found among his master's apparatus an old iron 
affair which he thought must have been used to break up callus ; as it 
was highly complicated, he set to work to simplify it, and in 1783 
he used it successfully on a fracture of the femur, united at an angle, 
and dating back twenty-eight weeks. A second attempt, as fortunate, 
was made on a fracture of the leg the date of which is not given, 
and subsequently several more; but nothing had been published 
concerning these operations, until in 1811 Oesterlen had occasion to 
see Bosch use his apparatus under the following circumstances. 

A young man of twenty-six had had his right femur broken at about 
the middle, by a fall from a carriage, and had been so carelessly 
treated that the fragments made an angle forward and outward like 
that of the knee when semiflexed, and the limb was shortened more 
than four inches. The fracture was sixteen weeks old. Bosch made 
him lie on a table, had counter-extension made by two assistants 
with a cloth around the perineum, and extension by two others, and 
applied his apparatus; this resembled very much a bookbinder's 
press, two boards being brought together by means of two screws 
placed toward the ends. The thigh was put into the press, directly 
across it ; then in order to moderate the pressure, a very wide roller 
was placed on the projection of the callus, the upper board pressing 
on the upper side of this roller. Extension being now steadily 
made by the assistants, the operator rapidly turned both screws at 
once, until the patient complained of pain at the seat of fracture. 
Then the assistants were directed to increase the extension, while 
the screws were worked more slowly, though without stopping, till at 
last crepitation was distinctly heard, when the extension was taken 
off and the machine removed. This however was not all; Bosch had 
the thigh raised by two assistants, at first gently, and afterwards 
forcibly, while he himself pressed with both hands on the angle of 
the fracture ; crepitation was again heard ; the patient complained 
of greater pain; and some mobility became apparent. In order to 
disengage the fragments, an assistant passed a cloth round on the 



A TREATISE ON FRACTURES. 271 

inner side of the fracture, and then pulled outward on the ends with 
all his strength; while the operator, placing his left hand on the 
inner side of the thigh, above the callus, and his right on the out- 
side, below it, sought by thus pushing in opposite directions to com- 
plete the fracture; this at last occurred with renewed crepitation, 
and now the fragments, disengaged from one another, could be reduced. 
The operation lasted in all ten minutes; there was neither contusion 
nor ecchymosis ; the pain, which seemed to be caused more by the 
extension than by the pressure, was much relieved. The subsequent 
course of the case was very simple; eleven weeks afterwards the 
patient began to go about : the shortening was only a little over two 
inches, or in other words, there were gained twenty-one lines in the 
length of the limb by the operation. 

In 1817, Oesterlen assisted at an operation of the same kind for a 
fracture of the leg sixteen weeks old, which was still more completely 
successful ; and he relates five other observations communicated to 
him by Bosch; viz.: a fracture of the humerus which had occurred 
at birth, of six weeks' date; a fracture of the leg, three months; a 
fracture of the arm, six months ; and two fractures of the femur, of 
five to six months.* 

Bosch afterwards improved his apparatus as follows : There were 
always in it two boards of beech-wood, fourteen inches long, five 
wide, and one and a half thick, joined by two screws, so that the 
distance between them could be altered at will ; but the lower one 
was furnished with two longitudinal hair-pads, intended to keep the 
limb up, leaving between them an empty space into which the callus 
might sink ; the other one had at about its middle a hair-pad about 
two and a half inches in diameter, intended to press directly on the 
callus. It should be added that the lower board had at each of its 
four angles a screw, to fasten it firmly to the operating table. 

[Dr. Gurdon Buck, in a communication macle in 1855 to the New 
York Academy of Medicine, related the history of six cases treated 
at the New York Hospital, in which old and badly-united fractures 
of the thigh were forcibly broken up, and the deformity corrected; 
in all these the result was favorable. (See Transactions of New York 
Acad, of Med., vol. i, part iv.) One of these cases is a very re- 
markable one ; it is that of a boy aged 5 years, who had a fracture 
of the left femur. The bone had been three times broken over again 
by a quack, to correct deformities of the callus; finally the boy came 
under regular treatment, and the operation was done for the fourth 
time, with a favorable result. 

On the books of the New York Hospital are recorded two artificial 
refractures, one of which, in the left femur of a young man aged 19, 
lessened the shortening of the limb from four inches to one and three- 



Oesterlen, op. cit. obs. 9 to 17. 



272 A TREATISE ON FRACTURES. 

(punier inches ; the other, in the left radius of a man aged 26, three 
inches above the wrist, was perfectly successful. 

In February, 1851, I saw Dr. W. E. Horner perform, at the clinic 
of the University of Pennsylvania, a refracture of the leg of a young 
man. The original injury had taken place twelve weeks previously; 
the patient was etherised, and the limb put up in splints so as to 
afford a better purchase; the case did perfectly well. 

In 1855 I myself refractured the left forearm of a boy aged 13, 
for a bending backward of both bones, consequent upon a fracture 
which had taken place three months before; simply grasping the 
forearm, which had just been again fractured below the angle, with 
both hands, and bearing it down over my knee, so as to efface the 
angle. The bones united without any deformity in six weeks.] 

Third Method; Section of the Callus. — This method consists 
mainly in dividing the integuments so as to act more directly upon 
the callus. Paulus iEgineta, as has been stated, used cutting forceps, 
and Fabricius Hildanus speaks of a stupid surgeon of his day who 
proposed thus to divide a callus ten months old; but it was left for 
the nineteenth century to see the plan put into execution ; yet I can 
only quote three such cases. 

Garden 1 , in a note to the Booh on Fractures of Hippocrates, says 
that he had had the bones of the forearm cut, in one of his nephews, 
at the original seat of fracture, two months after they had been set 
and bandaged in the supine position. The callus had formed well, 
but the child was completely crippled in the right hand; he could 
neither write nor grasp firmly with it. The operation was perfectly 
successful. 

I have related, in my Medecine Operatoire, the operation done by 
"Wasserfuhr on a child of five years, for a fracture of the femur of 
only three weeks' date. The fragments formed a right angle upward 
and outward; Wasserfuhr made over this angle an incision com- 
prising one-quarter of the circumference of the thigh, sawed partly 
through the callus and broke the rest of it, and succeeded perfectly. 

But a still better instance was furnished some years since by the 
London surgeons. The patient had had the tibia broken by a ball, 
and united angularly with so much shortening, that several surgeons 
had advised amputation. Mr. Aston Key and Sir Astley Cooper 
thought proper to attempt the section of the callus. An incision 
four inches long was made over it, the tibia was separated from the 
surrounding soft parts, and divided partly with a chain-saw and 
partly with an ordinary saw. This section made, it was found unne- 
cessary to cut the fibula in order to effect reduction. However, to 
keep the limb in place, permanent pressure was required, and made 
by two tourniquets so arranged as to push the thigh and foot out- 
ward. The symptoms were very slight; at the end of four months 



A TREATISE ON FRACTURES. 273 

the wound had cicatrised and the callus was firm, the shortening of 
the leg being but trifling.* 

Fourth Method; Resection of the Callus. — The first known ope- 
ration of this kind dates back only to 1815; Oesterlen communicated 
it to Lemercier. It concerned a fracture of the leg, of only forty 
days' standing, consolidated with great curvature ; three lines of the 
lower and outer end of the upper fragment were sawn off, and about 
as much of the upper and inner end of the lower one; three weeks 
afterwards there was every reason to hope for a perfect cure. 

A second attempt was made by Riecke in 1826. A young man aged 
20, having been treated for fracture a#the middle of the femur with 
Sauter's suspensory apparatus, was dismissed at the end of eight weeks 
with so much curvature outward, that the limb was shortened eleven 
inches; the upper fragment projected strongly against the skin, and 
the lower joined it at an angle, six or eight inches above the project- 
ing point. Riecke made a long incision, from near the trochanter 
down to the external condyle, detached the muscles from the bone, 
divided one-half the callus with the saw, completed the section with 
a hammer and chisel, and lastly resected some three lines of the 
wounded end of the upper fragment. There ensued fearful suppu- 
ration, and numerous necrosed splinters came away; and it was not 
till the eighth week that the patient was out of danger. Eight 
months were required for complete consolidation.")" 

[In 1850 I saw an operation performed by Dr. W. E. Horner, at 
the clinic of the University of Pennsylvania, upon a man who had 
sustained a fracture of the femur eighteen months before; the limb 
was shortened four inches. Dr. H. made an incision at the outer 
and back part of the thigh, sawed off the ends of both fragments, 
(the fracture had been a very oblique one,) and then made extension 
by means of pulleys until the shortening was reduced to half an inch. 
Gangrene and phlebitis carried off the patient in four days. 

It seems to me that the result of this case may be clearly traced 
to the great and sudden extension to which the limb was subjected.] 

So far, the resection is pure and simple, sometimes of one, some- 
times of both fragments, the object being to freshen up, as it were, 
their extremities, and favor coaptation; and under this head should 
be placed also two operations undertaken by Portal in 1837 and 
1840, the first for an angular callus of the leg, thirty-three days old, 
the second for an angular callus of the femur, forty days old. Less 
than two months sufficed for the cure in each of these cases. J 

But there is another method, devised in 1834 by M. Cldmot, of 
Rochefort, which consists in cutting away with the saw a wedge- 
shaped portion of the callus. A child. forty days old had an angular 

* Gazette Mtdicale, 1839, p. 366. 
f Oesterlen. op. cit., pp. 124 and 126. 
X Gazette Medicate, 1841, p. 601. 
18 



•274 A TREATISE OX FRACTURES. 

curvature of the femur, probably occasioned by the manipulations of 
the accoucheur at the time of its birth. After in vain employing for 

several months an apparatus for making extension, M. Clemot made 
an incision five centimetres long over the callus, separated the mus- 
oles from the outer three-quarters of the bone, and with a narrow 
saw removed a wedge comprising two-thirds of the thickness of 
the callus ; the remainder yielded to bending force, and the child 
was cured in seventy days. A similar operation was done for a 
similar affection in a man of twenty-seven, on the twenty-fourth day 
of a fracture at the middle of the femur.* 

M. Velpeau quotes anothtr case operated on by Warren, for a 
fracture of the tibia, and likewise attended with success; he does not 
mention the date of the fracture. 

[This operation has been not unfrequently performed in the United 
States, though the published reports are rare. A case occurred to 
Dr. Pancoast, of Philadelphia, about two years ago, quite illustrative 
of its value. It was that of a girl of twelve, who had broken the 
right leg about two inches from the knee, and recovered with the 
knee bent at a right angle, and the fracture firmly united at a some- 
what wider angle, salient posteriorly. The child's constitution was 
scrofulous. Her parents said they would prefer amputation to the 
leg as it was: and Dr. Pancoast determined on resection. Ether 
was given, and the inner hamstring muscle divided subcutaneously, 
so as to allow of partial straightening of the knee. Then an incision 
was made over the deformity, and a wedge-shaped piece was taken 
out from the tibia, leaving a small portion anteriorly to be ruptured 
by straightening the leg at the seat of fracture. This was now done, 
and the case treated like an ordinary compound fracture. The 
result was perfectly satisfactory, the child recovering with a very 
useful limb.] 

To form a serious judgment between these different methods, we 
should examine separately the three kinds of deformities of the callus 
to which their application may become necessary; and the first of 
these both in frequency and in gravity is certainly angular deformity, 
or considerable overlapping. 

Now on comparing, with regard to this, the four methods and the 
pertaining to each, we are first of all struck with one thing, 
viz., that with the exception of Aston Key's operation there is not a 
single one of the sections or resections of the callus which would be 
justifiable. Fractures of only three weeks, a month, forty days, at 
most eighty days' standing! Fractures united at an angle, the least 
firm of all forms of union; and lastly, in the majority of cases, in 
children, in whom we have soen the facility of correcting it! Cer- 

Bdsection du Ftmv.r pour un cal vicieux : Acad, de 
Kay 24, 1836. 



A TREATISE ON FRACTURES. 275 

tainly we must be indulgent toward the authors of such operations, 
since unhappily the silence of modern classical treatises would leave 
them convinced of the impotence of art; but at the present day, 
with the facts now known and established, considering the successes 
obtained by means of energetic extension and by machines for break- 
ing the callus, even in older fractures than those for which section 
or resection have been tried; if, moreover, we think of the danger 
attending these bloody operations, the most moderate conclusion 
must be that we should never resort to them without having first 
tried the other two methods. 

I would go further; before attempting to rupture the callus by a 
machine, the various other plans for adjustment should be exhausted. 
The time that has elapsed since the fracture is not an objection, at 
least in all cases ; we have seen, moreover, to what delays and hin- 
drances consolidation is subject; and it is to be noted that the 
greater the angle formed by the fragments, the less solid is the 
callus. Besides, between the tourniquet of Desgranges, the vice of 
M. Thierry, and the machine of Bosch, there is but little difference, 
and that lies more in their use than in their construction. Bosch 
himself, notwithstanding the power of his machine, has hardly gone 
beyond the limits fixed by Guy de Chauliac and the other advocates 
of adjustment. They would let the callus alone if it were more than 
six months old; once only did Bosch attempt a fracture somewhat 
later, but even that was but six months and a half. 

Thus then, we try first adjustment, and afterwards rupture. There 
have however been raised, against this latter method particularly, 
two objections which it is important to examine; first, the danger of 
breaking the bone at some other point; and secondly, in some cases, 
the fear lest the rounded ends of the fragments should not be capable 
of uniting. 

The first of these objections is nearly valueless when we make use 
only of extension or of gradual compression ; and when a resort to 
rupture becomes necessary, I think that by observing the precautions 
given by Bosch we are equally certain as to the result. In fact, we 
never meddle with the callus unless it is very much deformed; and it 
suffices to look over the accompanying engravings to be convinced, 
that however little the fragments may deviate from the normal di- 
rection, the callus is always formed of spongy tissue, and is therefore 
easier to break than the diaphysis, unless there be some special dis- 
ease of the bone. Lastly, besides our observations on the living, 
our experiments on the dead body would make us certain on this 
point. I have already (page 262) quoted M. Jacquemin's experi- 
ments on recent fractures ; let us examine some others on fractures 
of much older date. 

A three-year-old bull had had the cannon-bone fractured, and re- 
united at a considerable angle. Six months and a half afterwards, 



°.,6 A TREATISE OX FRACTURES. 

j killed : Bosch and Oesterlen tried breaking the callus by 
3 of a jack, and the rupture took place without splinters, and 
without any injury to the original fragments. 

ir-old roebuck had had the right haunch-bone fractured, 

and reunited at an angle. Five months and a half after the frac- 

be animal was killed, and Oesterlen tried breaking the callus 

with Bosch's improved machine. Here also the rupture occurred 

38 the callus.* 

■ :her objection was put forward by Sanson; it does not con- 
cern callus which is merely angular, but only cases of overlapping, 
with or without angular deviation. Here, said Sanson, the frag- 
ments will not unite, because their extremities will be cicatrised. 
M. Laugier has replic .: it was not union which was defi- 

cient in the cases of rupture of malformed callus : (2) that even 
supposing the ends of the fragments not to be in a favorable state 
for reunion, they would unite in great part by the new surfaces of 
the osseous or cartilaginous callus. 

On the whole, these objections seem to be more plausible than 
real, and are not such as would deter a surgeon from the operation, 
where the existing indications were sufficient. But it is these indi- 
cations which must be seriously discussed : for although so far we 
have seen only successes, we must not consider either rapture or 
adjustment always such safe operations. Among the Arabian-. Ali 
Rodoham saw an old man of seventy, who, having placed himself in 
the hands of a bone-setter, died under the operation.^ Morgagni 
saw also a physician who, having caused a still very recent fracture 
of his leg to be broken up again, was attacked with the worst symp- 
toms, and finally succumbed : and M. Laugier relates the case of a 
fracture of the femur united with an inch and a half shortening, 
which at the end of nine weeks was subjected to forcible ex: 
with pulleys : the callus was broken up, but the patient died in an 
hour and a half afterwards. t 

Thus, like all other operations, these have their dangers, which 
must be weighed against their possible utility. Assuredly, before two- 
thirds of the time necessary for consolidation has r while 

there is still mobility between the fragments, we nee 
again perform reduction, provided we can certainly keep it up. When 
Qua seems \n within the first month, thei 

obs. 18 and 29. 

the authority of Guy de Chauliac and Joubert. fa universally 

. bas. Now there is not in all the extensive treatise I H./.y 
_'.-.• word relating to it; and more- tee the 

third book of the Zfecftne, which never belonged to Haly Abbas. Ali B 

commentary on th ' of Galen ; and it was in 

fact there that he found this case mentioned. 

- .. Epist LVI. I xxviii: Laugier, Des 

l.p.62. 



A TREATISE ON FRACTURES. 277 

great deformity, and great interference with the functions of the 
limb, to justify us in attempting either adjustment or rupture. But 
when these two conditions exist, making the limb rather a burden to 
the patient than an assistance and support, it is, in my opinion, never 
so late that art cannot or ought not to afford the necessary aid to the 
sufferer ; and after an ineffectual trial of rupture, I should no longer 
hesitate to perform either section or resection. 

So much, then, for angular callus or great overlapping. The second 
variety of malformed callus comprises the fusing together of two 
parallel bones, such as those of the leg or of the forearm. M. Lau- 
gier has made an interesting observation on this point; it is that 
this fusion of the two bones does not always take place from one 
fracture to another, but sometimes between a fracture of one of the 
bones and a healthy portion of the shaft of the other. An appa- 
rently essential condition is that both bones should be broken, but 
not at corresponding points. An example of this kind of fusion of 
the tibia with the fibula may be seen in Figs. 89 and 90 ; it is less 
common in the forearm than in the leg, though it is well to be aware 
of its possibility. 

As one might suppose, in the leg such a condition would be with- 
out inconvenience, and even sometimes impossible to recognise; but 
in the forearm it is a different affair, involving the absolute loss of 
the power of pronation and supination. Thus, since the time of 
Celsus, it has been considered a legitimate reason for forcible adjust- 
ment ; but it must be admitted that this is a plan more easily advised 
than put in practice. I have been able to find but one case of this 
kind in which an operation was attempted ; it is the one mentioned 
by Gardeil, in which it would seem that section of the callus was 
performed. I shrink from laying down any law on this point, leaving 
the question to be decided by each surgeon according to his own 
judgment. 

There remains only the third form, — when a fragment projecting 
beneath the skin or among the tissues becomes a source of continual 
pain and irritation. When the callus is soft, to attempt to restore it 
to its place is a matter as simple as it is natural; but if the callus is 
hard, and does not otherwise hinder the functions of the limb, it 
would be absurd to try to destroy it in any way ; the only indication 
is to resect the projecting point. 

It is stated that Ignatius Loyola, having had his thigh broken 
during the siege of Pampeluna, and having recovered with deformity, 
caused the callus to be broken up; but he was again so carelessly 
treated that one of the fragments formed a prominence above the 
knee ; and the patient, it is said, had this end resected. This was 
the first instance of resection of a bony fragment in a fracture of 
long standing. 

A resection of this kind was performed by M. Velpeau upon a 



278 A TREATISE ON FRACTURES. 

woman, who, in consequence of a comminuted fracture in the lower 
fourth of the humerus, had one of the fragments forming a long 
sharp ridge under the skin, above the epicondyle. As this ridge 
gave her pain, and interfered with the movements of the forearm, 
she desired to get rid of it. An incision two inches* in length along 
the outer part of the humerus laid bare the bony prominence, which 
was removed with cutting forceps. The wound healed by the first 
intention. 

Frequently, after oblique fractures of the leg treated by the ordi- 
nary means, there remains a sharp point of one of the fragments 
beneath the skin. M. Velpeau mentions the case of Meyranx, who 
had to the day of his death such a projection, causing ulceration and 
almost constant pain. Resection would have been the only remedy; 
and the operation is so simple, and so free from danger, that we can 
but wonder, with M. Velpeau, that science possesses so few examples 
of it.* 

[It would seem as if the rarity of this operation might be easily 
accounted for by the rarity of the cases demanding it ; and this 
again by the fact that almost always Nature herself takes charge of 
the case, the sharp points becoming softened, rounded off, and ab- 
sorbed. Such a process may more readily occur when the offending 
portions of bone still retain their vitality, so that the work of their 
removal is not yet beyond the province of absorption ; this condition 
once lost, the surrounding tissues can keep no terms with the dis- 
turber, and the difficulty can only be allayed by its ejection, sponta- 
neous or artificial.] 

Before closing this section, I may mention that I have proposed, 
in cases where section of the malformed callus seems indispensable, 
to introduce by a narrow wound a steel chisel, and to drive this by a 
leaden mallet, so as to break the callus without admitting the atmo- 
sphere to it; even if this latter object were not attained, the rupture 
would be made with less disturbance, and the conditions of a recent 
fracture more closely approached, than by using a saw through a 
large incision. 

§ XVII. — Of some Diseases of the Callus. 

It is not my purpose to revert here to the softening of the callus 
from scurvy, erysipelas, etc., which was mentioned in connection 
with false joint ; but we may properly study by themselves certain 
affections peculiar to the callus itself, either before or after its com- 
plete consolidation ; a subject by no means unimportant, and far too 
much neglected by surgeons. I shall dwell successively upon pain 
in the callus, exuberance of it, and the fleshy granulations to which 
it may give origin. 

* Velpeau, Mid. Opdratoire, second ed., tome ii, p. 599. 



TREATISE OH FRACTURES. 279 

(1.) Of Persistent Pain in the Callus. — There are a great many 
fractures, especially among such as are united by a deformed or vo- 
luminous callus, which give rise to pains, sometimes acute, sometimes 
dull, recurring at every change in the weather. Theden broke his 
right humerus three inches above the elbo^; the fracture, although 
attended with great Buffering, was consolidated in seven weeks. But 
during the whole of the ensuing year, the least change of weather 
was announced to him twenty-four hours beforehand by severe pains 
both within and around the callus. He applied his compressory 
bandage, with relief to the outward pains ; in time the internal pains 
became likewise more endurable ; but at the end of ten years he still 
felt them occasionally. 

I have known these pains to persist after several years in a young 
person of twenty, who had sustained a fracture of the clavicle. I 
have likewise observed them in adults and old people, to whom, ac- 
cording to their expression, they served as a sort of barometer. 

Now what is their nature ? The'den ascribes them to the pressure 
exerted on surrounding parts by the material thrown out for the 
callus, and by the hindrance it involves to the circulation of the fluids 
in the periosteum and marrow. " Je sentois parfaitement." he says. 
"l'impulsion des liqueurs sur le cal; je pouvois distinguer celle qui 
se faisoit interieurenient."* This view is too hypothetical to demand 
attention ; all that we can say on this head is that it is with the 
callus as with cicatrices in the soft parts, which also give rise from 
time to time to barometric pains ; and just as cicatrices which have 
been the slowest to form are generally the most painful, so also 
vitiated callus is more troublesome than the ordinary. 

We must not confound these pains recurring in an old and firm 
callus with such as depend on some defect or hindrance of consolida- 
tion. I have seen numerous examples of such ; the simplest and 
surest remedy is then to keep the limb in an apparatus as long as 
may be necessary. A young girl made a misstep, and was thought 
to have sustained a simple sprain ; at the end of twenty-five days, 
the ankle-joint being supple and painless, she was allowed to walk 
about. But soon severe pains, developed at the lower part of the 
leg, absolutely prevented her from putting her foot to the ground. 
It was not known what could have caused them ; the circumstances 
of the accident, and the localisation of the pains at one point in the 
fibula, led me to diagnose a fracture of this bone ; and an albunii- 
nated apparatus, worn for three weeks, produced a complete cure. 

In this case, the fracture had not been recognised ; at other times 
the fracture is clearly made out, but subjected to some hindrance, 
revealed before long by the pains. The treatment is the same, and 

* Theden, Progrls ult. de la Chirurgie, translated from German into French. 
Paris, 1777, pp. 42 and 139. 



280 A TREATISE ON FRACTURES. 

is almost certain of success ; if, however, the pains persist, they may 
bo dissipated by a blister at the point of fracture. A patient affected 
with a fracture at the upper part of the femur, treated at first by 
permanent extension, which he could not endure, and afterwards by 
ordinary splints, had tried to go about at the end of twenty-four 
days. The limb appeared firm; pains, however, were soon felt at 
the level of the callus. The application of another apparatus not 
having availed to relieve these, I used three flying blisters in succes- 
sion, with the desired effect. 

(2.) Of Exuberance of the Callus. — Certain fractures, principally 
those of the upper fourth of the femur, below the trochanters, are 
surrounded by callus to such an amount as by its weight, its volume, 
and its projecting points, to interfere notably with the functions of 
the limb. I have represented such a case in Fig. 72 ; but I have 
seen them even more voluminous. 

This exuberance of the callus strongly attracted the attention of 
the ancients. "When this occurs," says Celsus, "we must apply to 
the limb gentle and prolonged frictions with oil, with salt, and with 
nitre ; use copious fomentations with salt water ; apply a resolvent 
poultice ; increase the pressure of the bandage ; give a vegetable 
diet ; administer emetics ; all which means, by emaciating the soft 
parts, will likewise attenuate the callus. We may also prescribe a 
cataplasm of mustard and figs for the sound limb, so as to raise the 
epidermis, and attract thither the humors." 

Paulus iEgineta is bolder ; if local astringents, and compression 
with leaden plates are not sufficient, he advises laying the callus bare, 
rasping it, and removing all the projecting portion; if necessary, 
even applying the trephine. 

We find these precepts copied by the Arabians, and even by later 
writers ; I know, however, of no case in which they have been acted 
upon ; and if the callus be hurtful only by its volume, it would be 
certainly better, after having tried the gentle means proposed by 
Celsus, and perhaps douches and sea-bathing, to let the patient live 
with this annoyance than to subject him to an operation the doubtful 
benefit of which would not compensate for its danger. 

But sometimes there is joined to this hypertrophy of the callus 
another morbid condition : intense pains in the callus itself, with bad 
effects upon the entire limb. M. Guyot has given a remarkable in- 
stance of this, which is in every way worth mentioning here.* 

M. Turgot had sustained a fracture of the right femur in its upper 
third, by a fall from his horse. Dupuytren, who was called, applied 
at first nn eighteen-tailed bandage, with direct extension; at about 
the fiftieth day hie substituted for this the double inclined plane. This 

* (juyot, Des accidents conse'eutifs aux fractures : Archiv. de Mtdecine. 
Feb., 1836. 



A TREATISE ON FRACTURES. 281 

change of posture bent one fragment upon the other, with great 
swelling and intolerable pain ; the callus was slowly developed, and 
deformed. However, the patient walked about, when, to get rid of 
some remaining stiffness in the knee, he resorted to the waters of 
NeVis, [mineral springs.] Under the influence of these the callus 
swelled, and became the seat of severe pains ; the whole member be- 
came (edematous and of a deep violaceous tint. The limb was now 
useless as a support; the slightest shock on the point of the foot was 
acutely felt in the callus and whole upper portion of the thigh ; and 
the patient could not rest his weight on the deformed callus without 
a sensation of fatigue increasing in a few minutes to actual pain. All 
the means employed failed ; it was only by the third year that the 
pain, swelling, and violaceous tint of the skin were in a measure dis- 
sipated by sea-bathing, but the other symptoms remained; and the 
patient could only walk with two crutches. Damp or stormy weather 
increased his uneasiness, even to an inflammatory condition, as shown 
by the swelling, pain, heat, spasmodic contractions of the muscles, 
and often fever. These accessions lasted from six to nine days. 

On examination, M. Guyot found the fragments overlapping, and 
forming a slight angle forward and outward ; but especially sur- 
rounded by an enormous callus, with great engorgement of the sur- 
rounding soft parts. Thinking at first that the bone was wanting in 
solidity, he attempted to supply this by means of a thigh-piece, which 
gave relief for a time, but then became insupportable. Gradual ex- 
tension by means of Boyer's mechanical splint seemed more effectual; 
in eight days the limb resumed its natural color and size ; but on the 
thirtieth day, a movement of the patient's having reproduced the 
pain, this remedy likewise was considered hopeless. Lastly, recourse 
was had to a large blister, which, having a good effect, was followed 
after some days by a second, and this by a third ; and in twelve 
days after the first one was put on, the patient was able to get up, 
and to rest his weight on the diseased limb. In order to perfect the 
cure, it was thought fit to apply, on the outer and posterior part of 
the thigh, at the level of the callus, a cautery large enough to admit 
eight or ten peas ; and some months later the limb had entirely re- 
covered its color, form and functions. 

M. Guyot reports two other cases, analogous to this, but not so 
complete ; they also were fractures at the upper part of the femur ; 
in the second one, the pain was twice relieved by blistering, and 
twice reappeared, when the cautery finally put an end to it. 

This affection of the callus has exactly the character of a state of 
chronic inflammation, occupying its substance as well as involving 
the periosteum and the neighboring fibrous tissues. In the cases ob- 
served by M. Guyot, there were some symptoms of gout or rheuma- 
tism, which may perhaps have influenced the persistence of the 
pains. 



282 A TREATISE ON FRACTURES. 

In some cases the volume of the callus depends on its having a 
central cavity, ossification occurring only at the circumference; Pro- 
fessor Weinhold, of Halle, suddenly entered a cavity of this kind in 
endeavoring to transfix the callus with a seton. This attempt ought 
the rather to be known, since it was followed by success. 

A young man of eighteen, who had sustained a fracture at the 
middle of the femur, undertook to walk and to resume his occupa- 
tion at the end of the fourth week. Six weeks afterwards, the limb 
was shortened by two inches, and the callus was enormously increased 
in volume ; its circumference was eighteen inches and a half; the 
surrounding cellular tissue was engorged, and at different points 
there were abscesses formed, tending to become fistulous. Weinhold 
at first tried extension with pulleys, but the callus did not yield. He 
then conceived the idea of passing a seton through, in order to pro- 
voke suppuration and softening of the callus, with a view of again 
trying extension. Therefore, with a trepanning-needle * mounted on 
a brace, he pierced the soft parts at about an inch from the femoral 
artery, and gently perforated the outer layers of the callus ; after 
which the instrument suddenly went about four inches deep before 
reaching the opposite wall ; the callus being perforated anew at this 
point, the needle was pushed through the muscles and skin, and the 
seton introduced. The part was for three days dressed with cold 
poultices; on the fourth the seton was smeared with balsam of Arceus 
[something similar to our Elemi ointment,'] and then pulled upon 
twice daily. By the fifth week a copious suppuration, flowing at 
each opening made by the seton, resolved -the engorgement of the 
cellular tissue ; then the fistulse closed up ; the callus in its turn in- 
flamed and suppurated ; at least so Weinhold thought, from feeling 
it yield under the pressure of his finger. He now resorted again to 
extension, and with such success that by the tenth week the limb was 
only shortened two lines. For greater security, the seton was still 
retained for fifteen days ; and some weeks later, the wounds were 
cicatrised, the thigh was of its normal size ; the patient could walk 
without crutches, and in the end he recovered nearly his former 
strength. f 

(3.) Of Fungous G-roivths from the Surface of the Callus. — This 
complication naturally implies a communication externally of the 
fracture or of the tumor formed by the callus ; the only instance of 
it which I can cite was the result of gunshot fracture ; and it will be 
noticed that the callus was in the same condition as in Weinhold's 
patient, hollowed out internally, ossified at its circumference. 

A soldier received a shot which broke his left thigh just below the 

* ["Aiguille d trypan." The precise form of this instrument is not stated ; it 
may be that the author means the perforator deprived of the crown of the 
trepan.] 

t Archiv. G6n. de MMecine, 1828, tome xvii, p. 446. 



A TREATISE ON FRACTURES. 283 

great trochanter. The necessary incisions were made for the ex- 
traction of the ball and of the other foreign bodies ; but in spite of 
the treatment adopted, — probably from scurvy, with which the man 
was attacked, the fracture was unconsolidated at the end of six 
months. Granulations had sprung up in the wound, and from them 
there was lost at each dressing quite a quantity of blood ; more than 
five months elapsed without any great improvement. A new surgeon 
now taking charge of the patient, discovered several sinuses formed 
on the anterior and inner part of the thigh, and opened them ; he 
also tried to destroy the fungus with weak caustics ; all this failing, 
he determined to saw off more than a finger's-breadth of the lower 
fragment, which by its overlapping irritated the neighboring parts 
and caused very severe pain. He did not succeed, as he had hoped,, 
in thus obtaining coaptation; but all the symptoms were moderated, 
exfoliation ensued, healthy suppuration was set up ; and in two 
months' time the callus acquired great firmness. Nevertheless, the 
wounds would not cicatrise ; and the patient, exhausted at length by 
pain and suppuration, died after five years and nine months of 
suffering. 

At the autopsy, it was found that" all the fistulse opened into a 
large cavity in the middle of the callus, which was very large and 
irregular ; this cavity was lined by a kind of membranous pocket, 
pretty thick, of soft consistence and whitish color, and which in 
spite of the presence of the pus, had defended the callus from caries ; 
while the sinuses, extending widely, had exposed and made carious 
the great trochanter and the coxo-femoral articulation.* 

§ XVIII. — Of Cases Requiring Amputation. 

Some fractures are so serious, either from their original character 
or from their consequences, that amputation may become the patient's 
only chance of safety, or a desirable means of relief from insupport- 
able infirmities. In the first case the operation may be either pri- 
mary or secondary ; in the second, it is always performed a good while 
after the occurrence of the fracture, and may be called consecutive. 

(1.) Of Cases Requiring Primary Amputation. — I have no inten- 
tion of treating this subject at any length, as it belongs quite as much 
to the study of amputations in general as to that of fractures; it will 
be sufficient for me briefly to sum up the principal indications. In 
general we are called on to amputate: 

When, besides the fracture, there is almost complete division of 
the soft j) arts. We should however make an exception in some in- 
juries by cutting instruments; not only have fingers been made to 
adhere after being cut off, but so also have nearly complete sections 
of the metacarpus, of the metatarsus, and even of the arm. 

* Miraoires de V Acad, de Chirurgie, tome iv, p. 625. 



284 A TREATISE ON FRACTURES. 

W!>> n the bones are so crushed as to make union appear impos- 
sible. 

When, the fracture being simple, the soft parts are so mashed and 
bruised that gangrene seems inevitable. 

When the great nervous and vascular trunks are both destroyed. 
When there is fracture into a joint, with extensive opening into a 
large articulation* This rule seems to me to be absolute as regards 
the knee-joint, although some instances are given to the contrary; 
in the other articulations exceptional cases are quite frequent. 

Lastly, when the fracture is complicated with spontaneous emphy- 
%tma, without any communication with the air-passages. — I shall 
dwell particularly on this complication, since the classical treatises 
pass it over in silence, M. Yelpeau alone making mention of it. He 
states in his Medecine Operatoire, that he has seen it in six patients; 
once in the arm, with recovery, and five times in the leg, with three 
deaths. More recently, the G-azette des Hopitaux has published 
another case occurring in his wards, a fracture of the forearm with 
a wound and emphysema; in spite of all his efforts, gangrene came 
on and spread, and on the eleventh day the patient died.* In 1836, 
M. Martin de Bazas called attention to this subject, and published 
the two following cases. 

A young man, aged 20, of good constitution, had his right hand 
caught between a wall and the end of a barrow he was rolling; there 
was contusion of the soft parts of the fore and middle fingers, the 
first phalanges of which were fractured. Some hours after the acci- 
dent, the surgeon who was called found an emphysematous swelling 
extending up to the elbow. In spite of antiphlogistic treatment, 
there ensued very intense inflammation of the lymphatics, which 
from the wounded part spread gradually over the whole of the arm, 
the axilla, and the front of the thorax. An inflammatory oedema 
had superseded the emphysema, all trace of which was gone; the 
fever was intense; on the seventh day tetanic symptoms appeared, 
and the patient died on the night of the tenth day. The autopsy 
revealed a transverse fracture of the first phalanges of the fore and 
middle fingers, with contusion of the tissues, and laceration of the 
vessels and nerves; the entire subcutaneous tissue of the limb was 
gorged with a reddish serosity, without any sign of air or of pus; 
the deeper structures and the nervous trunks were sound. 

Although death ensued, this was a case of benignant emphysema, 
since it did not occasion gangrene. This fearful consequence was 
present in the other case. 

A mason, while tearing down the front of a wall, had his right 
foot completely crushed, and the tibia and fibula broken, with lacera- 

* Velpcau. Mtd. Op6rat., second edition, tome ii, p. 321 ; Gazette des Hopi- 
taux, 1844, p. 458. 



A TREATISE ON FRACTURES. 285 

tion of the soft parts and protusion of the muscles of the calf. The 
hemorrhage was stopped by means of a roller; but the patient hav- 
ing been six or seven hours afterwards carried to the hospital, an 
emphysema was remarked, commencing immediately above the knee, 
involving the whole thigh, and losing itself in the lumbo-abdominal 
cellular tissue. Amputation was proposed, but the patient refused 
to submit to it, and twelve or fifteen hours after the accident he was 
no more.* 

M. Colson witnessed another instance of this in a fracture of the 
fibula, with luxation outward of the foot and protrusion of the tibia 
inward through the skin. Two emphysematous patches reached to 
the upper third of the leg; thirty-six hours afterwards gangrene 
commenced at the wound, and the patient submitted to the amputa- 
tion of the limb, which at first he had refused ; it was done on the 
eighth day. The gangrene had seemed to be limited, but this was 
an error ; four days later, all the skin on the outer side of the stump 
was sphacelated ; gangrenous abscesses formed in the thigh, and the 
patient died eighteen days after the operation. f 

Perhaps this recrudescence of the gangrene might be charged to 
the delay in amputating; at least I was more successful under ana- 
logous circumstances. A woman of sixty-five, in good health and 
of strong constitution, had been thrown down by a dray, and had 
the tissues and the bone of her right arm crushed, the leg of the 
same side sustaining also a comminuted fracture near the ankle. 
This second fracture communicated with the air only by a very small 
wound situated at the outer side of the lower third of the leg ; but 
emphysema extending nearly up to the knee made me think amputa- 
tion necessary; both the arm and the leg were therefore removed 
some hours after the accident. On removing the dressings of both, 
on the third day, the arm was doing wonderfully well ; but all the 
skin intended to form the stump of the leg was gangrenous. How- 
ever, the gangrene went no further, and I had the satisfaction of 
curing my patient. 

Still it must be confessed that along with these very frightful 
cases. «there are others in which spontaneous emphysema assumes 
the mildest form in the world. I cannot say what occurred in the 
three .successful cases seen by M. Velpeau, whether or not they pre- 
sented symptoms such as have been mentioned. But M. Martin re- 
lates a case of emphysema of the upper extremity extending up to 
the chest, complicating a gunshot wound of the forearm, but without 
fracture. Except some counter-openings which were thought neces- 
sary, the emphysema was productive of no trouble, and gradually 
passed off. Alight we not suspect that in this case the emphysema 
began in the thorax, thus completely explaining its harmlessness ? 

* Martin, De I'emphyseme traurnatique ; Gaz. M6dic. } 1836, p. 343. 
f Journal des Conn. M6dico-Chir., Oct. 1840, p. 148. 



2SG A TREATISE ON FRACTURES. 

On the whole, spontaneous emphysema in fractures is one of their 
gravest complications, and almost always calls for primary amputa- 
tion. How is it caused? Whence comes its fatal effect? These 
are two difficult questions. In a case of crushing of the foot in 
which M. Simonin had performed Chopart's amputation, the patient 
died on the fourth day; and there was observed just at the time of 
his doath an enormous emphysema of the leg. At the autopsy, a 
candle being held to the gas forming the emphysema, caused it to 
take fire with a slight report, and with a blue flame. Another case, 
in which death ensued twelve hours after a fracture of the skull, pre- 
sented the same phenomenon.* But these two persons being both 
much addicted to the use of spirituous liquors, M. Simonin had 
ascribed to this habit the modification of the solids and fluids which 
gave rise to the emphysema; this, moreover, as far as we are in- 
formed, was only perceived after death. 

I think for my own part that there occurs in the tissues, under 
the influence of the shock and stupor, a special alteration affecting 
their vitality, just as excessive cold kills the germ in the egg, and 
destroys the life in a clot of blood, without any change appreciable 
to the sight. The exhalation of a more or less deleterious gas is the 
only indication of this, and this symptom almost always points out 
the imminent approach of gangrene. I have sought to investigate 
the nature of these gases; in a subject affected with spontaneous 
gangrene, from a lesion of the soft parts of the thigh, death having 
taken place on the fourth day with mortification of nearly the whole 
limb, the emphysematous parts were opened two hours after death, 
and emitted a gas which took fire from a candle, burning with a bluish 
flame. Four hours afterwards, M. Joffroy collected at my request a 
quantity of this gas sufficient for analysis, and recognised it as car- 
buretted hydrogen, mixed with not more than one-fifth of atmospheric 
air. I inquired besides carefully into the habits of the deceased, and 
learned that he had been remarkably sober, f 

Is this gas, collected after death, identical with that of emphysema 
during life and before gangrene occurs? Would the same gas be 
always exhaled; or are there different sorts, corresponding to the 
different degrees of alteration present, and thus explaining the oc- 
casional mildness of the symptoms consecutively induced? Further 
observation alone can enlighten us in this respect. 

Such are, on the whole, the six great indications for primary 
amputation, and there is not one of them which has not sometimes 
been remarkably set aside. To say precisely when they are to be 
rigorously followed, and when we may depart from them with safety,* 
seems to me to be impossible; each surgeon must decide this from 
his own experience. 

* E. Simonin, Decade chirurgicale, Paris, 1838, obs. 1. 
f See my Journal de Chirurgie, April, 1845. 



A TREATISE ON FRACTURES. 287 

(2.) Of Cases Calling for Secondary Amputation. — These are 
chiefly extensive suppurations, dissecting up the muscles and bones, 
invading the joints, and threatening daily to spread higher; — exten- 
sive gangrene of the soft parts ; — necrosis or caries of a large portion 
of the fragments ; — -an enormous diffused aneurism ; — the occurrence 
of tetanus. I have already said how uncertain a resource amputa- 
tion is in this last case, and the other indications also are often open 
to quite different interpretations at the bedside. Besides, they do not 
belong more essentially to fractures than to other lesions. 

(3.) Of Cases Calling for Consecutive Amputation. — There are of 
these three principal ones, viz., pseudarthrosis resisting all treat- 
ment; — an irremediably deformed callus, making the limb a burden 
and hindrance to the patient; — disease of the callus, known to be 
incurable, or indefinite in its duration, such as the successive exfolia- 
tion of splinters during ten or fifteen years. Here the surgeon incurs 
a still greater responsibility than in the preceding cases; for while 
in them amputation was the only chance of safety, here life is not 
, threatened, and it is amputation which would endanger it; in a word, 
it is an operation of complaisance. 

I must not omit here a remark which is not without importance. 
In amputating for obstinate pseudarthrosis, the upper fragment has 
generally been sawn through. I think there would be a real ad- 
vantage in amputating directly at the false joint itself; we should 
thus at least avoid the risk of inflammation of the medullary tissue, 
the central canal of the bone being obliterated at the extremity of 
each fragment. 



CHAPTER II. 

OF FRACTURES OF THE UPPER JAW. 

The upper jaw comprises the majority of the bones of the cranium 
and face. We are not concerned here with fractures of the skull, 
the gravity of which depends wholly on the lesion of the brain, and 
the study of which is connected essentially with that of wounds of 
the head. But before passing to fractures of the facial bones, I 
would say a few words touching an extremely rare injury, which 
attracted particularly the notice of the ancients ; fracture of the 
auricular cartilages. 

Hippocrates and Celsus speak of it as a fracture; Galen thought 
this term improperly applied to it; Paulus iEgineta mixed it among 
contusions, and it is passed over by subsequent authors. I was 
therefore strongly disposed to believe that Hippocrates had had in 
view only contusions or lacerations of the ear, when recently M. Me- 
niere has spoken of actual fracture of the cartilage. 

" The muscles, the cellular tissue and the fibro-cartilage forming 
the pavilion of the ear," says he, "quite frequently undergo a form 
of alteration in virtue of which they become hard and stiff, so much 
so that this organ may be fractured, as I have seen it in a man thirty- 
eight years of age."* 

I have given this passage verbatim, not without 'regretting the 
excessive conciseness of the author. 

The fractures of the bones of the face which will form the subjects 
of the succeeding sections, are those of the zygomatic arch, malar 
bone, nnsal bones, and upper maxillary bones. All these bones are 
joined together, forming as it were one solid block; they are at the 
same time united to the bones of the cranium; hence there are 
some characters, common to all their fractures, which may thus be 
summed up: 

They are almost always the result of a direct blow; — their essen- 
tial sign is depression ; — and they are frequently complicated with 
concussion of the brain. 

* Gazette Mtdicale, 1841, p. 530. 
(288) 



A TREATISE ON FRACTURES. 289 



§ I. — Fracture of the Zygomatic Arch. 

This fracture is very rare ; Duverney was the first to speak of it. 
I have never myself met with it, and have only been able to collect 
five cases ; even these are not all free from doubt. 

It is usually the result of violence from without, a direct blow, or 
a fall; Duverney however relates the case of a young child who, 
having in his mouth the end of a lace-bobbin, fell head-foremost, so 
that the end of the bobbin, piercing the soft parts, broke the zygo- 
matic apophysis from within outward. Can it not also take place 
from an indirect cause? M. Tavignot exhibited to the Societe Ana- 
tomique the cranium of an epileptic subject, who having during a fit 
received a violent contusion on the left side of the forehead, died on 
the fourth day, from injury of the brain. The autopsy showed a 
single fracture of the zygomatic apophysis, without displacement; it 
had not even been suspected during life.* 

Thus the fracture may be simple and without displacement, when 
the seat of the pain will be the main ground of the diagnosis. More 
commonly there are one or more splinters detached in the direction 
of the external violence. In the child mentioned by Duverney, the 
fragments projected outward ; he says in fact that the palm of the 
hand being applied over the cheek with slight pressure, the zygomatic 
apophysis zoas restored to its 'place. In all the other cases, there was 
depression of the fragments. 

[Henry Buck, aged 50, a colored sailor, was admitted into the 
Pennsylvania Hospital, in 1855, suffering from the consequences of 
the falling of some chain on his head and left shoulder, several months 
before. He had a fracture, firmly united with deformity outward, 
of the left zygomatic arch.] 

This fracture is in itself a trivial affair ; at the most it may some- 
what impede the functions of the temporal muscle. A more serious 
danger arises from the concussion of the brain produced when the 
external violence is not exhausted in the fracture itself; as is shown 
in M. Tavignot's case. 

But when the brain is uninjured, should we at once elevate the 
depressed fragments, and if so, by what means? Assuredly, if the 
integuments are intact, and the temporal muscle plays freely and 
without pain, the wisest plan is not to interfere. Under other cir- 
cumstances we must do something, and two methods have been 
proposed. 

The first is very simple, and could be applied in all cases, if its 
efficiency were better proved. Duverney explains it as follows : A 
soldier having been struck "with a piece of wood, swelling of the en- 

* Bulletins de la Soc. Anat., 1840, p. 138. 
19 



290 A TREATISE ON FRACTURES. 

tire cheek ensued, with great difficulty in either dropping or raising 
the jaw. " 1 examined the zygomatic apophysis," says the author, 
•'and felt heneath my finger a depression. I introduced my left 
forefinger into the mouth; pushing it on as far as possible above the 
first molar teeth, and at the same time from within outward, I ascer- 
tained by the touch that the apophysis was broken and driven in. 
As there was no way of elevating it or pushing the fragments out- 
ward, either with the fingers or with other instruments, I advised 
the patient to take a somewhat flattened bit of wood about as big as 
his finger, to carry this far back above the molar teeth, and to close 
the jaws as firmly as possible. Having done this for some hours, he 
felt some relief; he kept on, increasing the size of the bit of wood, 
and by this means the pieces resumed their place, being pushed out- 
ward solely by the contraction of the temporal muscle." 

I would not deny that this result was obtained ; but several 
points in the account need explanation. It suffices to examine a 
prepared skull, or to carry one's finger into one's mouth, to show 
that the zygomatic arch cannot be reached in this direction. Again, 
the muscle is less in relation with the arch than its tendon is, and 
even this is separated from it by a special cushion of fat. Probably 
those motions really disengaged the tendon, but without effecting 
complete reduction ; at all events, in such a case, there could be no 
objection to resorting to a plan so entirely innocent. 

M. Ferrier employed more energetic means. A porter loaded 
with a sack of coal fell upon his right cheek, the load coming upon 
the other cheek. He came to the hospital at Aries with a depression 
on the right side of the head, which was recognised as a fracture of 
the zygomatic arch, the fragments being driven in. M. Ferrier made 
an incision three lines long through the integuments, and attempted to 
pass the small end of a spatula under the broken ends ; but the tem- 
poral aponeurosis was in the way, and had to be in its turn cut 
through. The spatula then entered very easily, and by a to-and-fro 
movement the pieces were brought to their natural level. The little 
wound healed promptly; the patient was discharged on the seventh 
day, but the cure was perfect, and there was no deformity.* 

Dupuytren seems horrified at such an operation ; he once used an 
elevator, but it was through a wound which complicated the fracture. 
Inilaiiimation ensued; deposits of pus, making their way along the 
coronoid process, opened into the mouth; however, the patient was 
cured in six weeks, without deformity or any hindrance to motion. f 

It is quite evident, and Dupuytren himself remarks it, that these 
symptoms were caused by the violence of the blow; and nothing is 
proved against M. Ferrier's operation. Nevertheless, I repeat, it 

* Rolland, Obs. d'une fract., etc.; Bulletin des Sciences M6d., tome x, p. 
160. 
t Dupuytren, Legons Orales, second ed., tome ii, p. 202. 



A TREATISE ON FRACTURES. 291 

should not be resorted to unnecessarily ; but the indications once 
clearly made out, I would not hesitate a moment. 



§ II. — Fractures of the Malar Bone. 

This name is given to cases in which the malar bone is driven in, 
whether it be simply luxated from the surrounding bones, which may 
very well occur, or there be an actual fracture ; but it is very diffi- 
cult to ascertain whether it is the edges of this bone, or those of its 
neighbors which are involved. 

The instances of this injury are rare ; to produce it the blow must 
be very severe. Sanson states that he has several times seen it 
caused by the kick of a horse, and that there could almost always be 
felt on the bone an indentation, the trace of the iron shoe. 

The depression of the bone is a pathognomonic sign of this lesion ; 
but it may easily be seen that for the first few days the contusion 
and consequent swelling will mask the depression, rendering the diag- 
nosis very obscure or even impossible. Some other phenomena may 
then guide the surgeon, if the displacement is sufficient to cause com- 
pression of the infra-orbital nerve. Of this the following case was a 
remarkable instance. 

Pierre Saintot, a joiner, thirty-four years old, came into my wards at 
Saint-Louis, September 13, 1837. Eleven days before, he had received 
from an awkward workman in his shop a violent blow on the right 
cheek with a very large two-handed mallet. He did not become in- 
sensible ; but there ensued at once such swelling that his physician 
perceived only the contusion, and ordered venesection, and leeches 
to the part. He therefore applied to us only after the swelling had 
subsided. 

I easily recognised a fracture of the malar bone, with depression. 
The cheek of the right side was perceptibly less prominent than that 
of the left; four millimetres above the outer and inferior angle of the 
orbit, this bone jutted forward about four millimetres ; toward the 
zygomatic arch, it was on the contrary as much driven in, and the 
posterior portion of the arch consequently projected outward ; lastly, 
passing the finger along the lower edge of the orbit, there was met 
an abnormal prominence, painful, but too deeply buried by the swol- 
len tissues for me to say to what bone it belonged. The finger, 
carried through the mouth into the temporal fossa, could distinguish 
no trace of the fracture. On the whole, it appeared that the blow 
had driven in the posterior half of the malar bone, raising and carry- 
ing forward its anterior part. 

From the first moment, he had lost all sensation in the right half 
of the upper lip, and in a triangular space, whose base was formed 
by this and its summit by the infra-orbital foramen. The ala of the 



202 A TREATISE ON FRACTURES. 

and the gams, partook of this insensibility; as did also the 
upper teeth on this side. The mobility, on the contrary, was unaf- 
fected. When he chewed, he felt some pain in the anterior part of 
the temporal fossa, opposite the fracture; never in the masseter 
muscle. 

The day after his admission, I attempted to push the bone out- 
ward by carrying my finger through the mouth into the temporal 
: but my efforts were entirely futile. Six days afterwards, the 
patient insisted on another trial being made; this, although more 
force was used, succeeded no better, and moreover gave rise to swel- 
ling of the cheek, and to pain ; these however subsided in a few 
days. The sensibility gradually returned ; and on September 30, 
when I last examined him, he had feeling in all the teeth, and a 
little in the ala nasi; the numbness still continued in the other 
parts. 

It is seen that in this patient the depression was irregular, involv- 
ing only the posterior part of the bone. A superficial examination, 
or one obscured by swelling of the soft parts, might in such a case 
lead to error, making us consider the fracture as involving merely 
the zygomatic arch. It seems to me that Dupuytren himself made 
this mistake. An old man of seventy had been thrown down by a 
carriage ; a contused wound at the external angle of the eye showed 
that the principal shock had fallen on this point ; the patient was 
carried to the Hotel-Dieu, insensible. At his evening visit, Dupuy- 
tren thought he recognised a fracture of the zygomatic arch. Death 
ensued on the fifth day. At the autopsy the arch was found to be 
really fractured, but there was at the same time a depression of the 
part of the upper maxillary bone forming the sinus maxillare, 
which would seem to me to be nothing more or less than the malar 
bone.* 

When this fracture is attended with concussion of the brain, it 
disappears, so to speak, before the graver lesion which engages the 
surgeon's whole attention. In the simple form, it requires no other 
manipulation than what I used in my patient ; but we should remark 
the rapidity with which it becomes irreducible, all our efforts having 
failed on the twelfth day. 

I have seen another instance of fracture of this bone with quite 
opposite characters, but from a different cause. In one of the old 
men under my care at Bicetre, I was struck with the unnatural pro- 
minence of his left cheek-bone, and asked him the cause of it. He 
was an old soldier of the empire ; at the affair of Ulm, an Austrian 
hussar had given him a sabre cut which, crossing the cheek obliquely 
from the left ala nasi to the external angle of the eye, had divided 
the malar bone and thrown it strongly outward. At the lower border 

* Dupuytren, Lemons Orales, second ed., tome ii, p. 205. 



A TREATISE ON FRACTURES. 293 

of the orbit, the bone projected about five millimetres, and seven or 
eight millimetres at the outer border. The cheek-bone was thus 
made to project notably, while the temporal seemed on the contrary 
much deepened. The left eye had at first lost some of its power, 
but afterwards regained it. The only remaining annoyance was that 
the eyelids did not come into perfect contact, even in winking ; during 
sleep they were widely separated. Thus, while in the preceding case 
the depression of the bone had acted specially on the infra-orbital 
nerve, it was here the filaments of the facial, divided by the sabre, 
whose functions were impaired. 



§ III. — Fractures of the Nose. 

These are the most frequent of any of the fractures affecting the 
upper jaw ; yet they are very rare, since in the space of eleven years 
only twelve were received at the Hotel-Dieu. One only was observed 
in a woman ; so that this fracture is one of those which occur mostly 
in the male sex. All ages are subject to it, except perhaps early 
infancy ; the youngest of our twelve cases was thirteen years old, 
and the oldest sixty-eight. 

The causes are falls on the face, or more commonly severe blows 
given from in front or from one side. 

These fractures present several varieties. Hippocrates, besides 
fractures of the bones, admits those of the cartilages, and we shall 
see hereafter several instances where they seem to have been at least 
separated from the bones. 

J. L. Petit teaches that commonly but one of the bones is broken, 
the other being merely driven in, especially in persons who have the 
root of the nose flattened. Duverney on the contrary says that 
generally both bones are broken. Facts are wanting to prove 
this relative frequency, and at any rate the question is of but 
small importance. A more essential distinction was made by Hippo- 
crates ; sometimes the fracture is slight, without displacement, and 
may be treated as a contusion or a simple wound ; or there may be 
notable displacement, and then, according to the direction of the 
blow, the fragments are driven directly in or pushed to one side. 
An instance of this second form of displacement is seen in Fig. 13. 
The fracture has separated nearly transversely the lower portions 
of the nasal bones, and a very small portion of the ascending process 
of the right upper maxillary ; the fragment of the nasal bone of the left 
side has been forced to the right and a little backward, separating from 
the upper portion, which thus projects notably above, and without 
parting from the ascending process, the suture of which has also 
changed its place. The fragment of the right nasal bone has been 
divided again by a vertical split; its inner part, pushed to the right 



294 A TREATISE ON FRACTURES. 

and a little forward, is placed on the same plane as the lower frag- 
ment of the left nasal bone, so that the angle which they naturally 
form together has almost entirely disappeared; and another very 
mark nl angle, well seen in the figure, is formed by this part of the 
right fragment with its other part, which is slightly turned aside. 
This is moreover the only example of this fracture which I have been 
able to find in the museums of Paris. 

Fractures of the nose are often attended with great contusion or 
even wounding of the integuments. Commonly a slight flow of 
blood occurs from the nostrils ; sometimes it amounts to a hemorrhage, 
and Rossi says that he has seen it prove fatal before he had time to 
save the patient ; but this is most extraordinary. A rarer, but at 
the same time much less serious symptom, is emphysema. A young 
man had received a violent blow on the nose, without any other symp- 
tom at first than a quite severe pain ; but some hours afterwards, 
blowing his nose forcibly, he felt something like a flash of fire pass 
up the nose toward the left eyelid, which immediately became puffed 
up with emphysema. Dupuytren was of opinion that the air had 
entered by a rent in the mucous membrane opposite the union of 
the left lateral cartilage with the bones of the nose, which union had 
been destroyed. 

Besides these primary symptoms, others sometimes supervene as 
consecutive phenomena; thus, in the first place, the inflammation 
may go on to abscess, sometimes showing itself between the mucous 
membrane and the bone, sometimes beneath the skin, sometimes in 
both places at once ; of this J. L. Petit relates instances. If the 
suppuration be prolonged, it may induce partial necrosis. The 
consequences attributed to these fractures do not cease even here: 
Monteggia quotes, from a medical journal which I have not been 
able to find, a case in which a fracture of the nose seemed to be the 
determining cause of a fatal polypus ; but here we should perhaps 
recognise a predisposition more serious than the mere fracture. The 
following observation, taken from Duverney, shows how deplorable 
may be the consequences of fracture of the nose in some subjects. 

A woman having received a blow with the fist on the right side of 
the nose, enormous swelling ensued, which obscured all the symptoms 
of fracture. The bleeding from the nose was excessive; the menses, 
which were flowing, were checked; the nasal mucous membrane 
swelled so as to form a plug, filling up the entire entrance of the 
nostril. At the end of fifteen days a fluctuating tumor was observed 
near the inner angle of the eye, which being opened, there flowed 
out some very putrid liquid blood. The nasal bone was laid bare, 
and a small portion of it, separated from the cartilage, was removed. 
The patient was nearly well when a fistula lachrymalis was formed, 
on which Woolhouse operated. Some days after the operation, there 
sprang up a fungous mass, which could not be kept down, but 



A TREATISE ON FRACTURES. 295 

degenerated into cancer, and the woman perished after terrible 
suffering. 

I have so far alluded only to fracture limited to the nasal bones ; 
it is easily seen that the external violence will not always stop at this. 
Quite commonly part of the ascending process of the upper maxil- 
lary bone is included in the fracture, without adding at all to its 
gravity ; it was so in the case represented, and I have seen another 
instance in the living subject. 

A painter, thirty-one years old, fell twenty feet off a ladder, and 
crushed his nose on the pavement. The fracture was compound ; seve- 
ral incisions had to be made for the extraction of splinters, and the cure 
was not complete till after four months. I had occasion to examine 
it sixteen years afterwards ; a large cicatrix reached from the left 
nostril to two fingers'-breadth above the eyebrow; the bones of the 
nose were almost completely driven in, so that there were evident 
under the skin two lateral prominences nearly three centimetres [one 
inch] apart, which were the ascending processes ; the process of the 
left side presented also distinct traces of a fracture ; nevertheless, 
respiration was freely performed through the nostrils, and the patient 
had never had any epiphora. 

But if the fracture involves the nasal canal, there is reason to fear 
a very intractable fistula lachrymalis. Of this Boyer relates a case : — 

"A girl eight years old was kicked by a horse, causing fracture of 
the nose, with depression. There ensued considerable swelling and 
inflammation, which were treated, with a view of dissipating them 
entirely before proceeding to reduction. These symptoms went off; 
but now reduction was impossible, so that the nose remained flattened, 
and an incurable fistula lachrymalis ensued, from the injury to the 
nasal canal." 

It has been thought also that a fracture involving the bones of the 
nose might in some cases extend to the perpendicular and cribriform 
plates of the ethmoid. According to J. L. Petit, there ought to be 
fracture of the perpendicular plate whenever the blow falls perpen- 
dicularly; or if this plate resists, there should be concussion of the 
brain. Others have thought that the resistance of the perpendicular 
plate gave rise to fracture of the cribriform, which, according to 
Boyer, has been sometimes observed. We have not facts enough to 
decide positively as to these statements. But at all events, fracture 
of the nose is unhappily often complicated with fracture of the skull 
or concussion, like fractures of the other facial bones. 

The diagnosis is sometimes very difficult, even when there is nota- 
ble displacement, on account of the swelling ; if there is no displace- 
ment, it becomes almost impossible. I discovered by chance, in an 
autopsy on a young child, one of these fractures without displace- 
ment ; it had not even been suspected during life. In such a case, 
as is easily seen, the error would be trifling. 



290 A TREATISE ON FRACTURES. 

The prognosis is generally favorable. Whether simple or com- 
pound, most fractures of the nose are quickly cured. Hippocrates 
fixes the term for their consolidation at ten days, which may perhaps 
be a little too short; but Boyer's case, related above, shows with 
what rapidity the displaced fragments contract adhesions which ren- 
der reduction impossible. The bones have so much vitality as to 
unite, so to speak, by the first intention ; in the specimen represented 
in Fig* 13, we see no traces, either inside or outside, of any osseous 
deposit indicating provisional callus ; and the vertical fracture of the 
right fragment, like the median suture of the two fragments, is 
healed so as to leave almost no sign of any separation. 

The treatment varies in different cases. If there is no notable 
displacement, or if the fracture is such that no tendency exists to its 
reproduction after adjustment, we should apply no apparatus. The 
slightest bandaging compresses the fragments painfully, and is at any 
rate useless. L. Verduc was called to see a young surgeon who, he 
says, had luxated one of the nasal bones by a fall ; as he judged from 
the nose being twisted. To replace the bone, a little stick wrapped 
in a linen rag was introduced into the nostril with the right hand, 
pushing the bone strongly upward ; while the left thumb was pressed 
upon the root of the nose ; reduction was effected with a slight noise, 
and the cure was accomplished without any apparatus. 

When, however, the crushing is such that the displacement tends 
to recur, some means of retention becomes necessary. No author that 
I know of has treated this subject so much at length as Hippocrates. 
He insists first on the reduction, and the adjustment of the nose 
without and within. The process is the same in all cases, consisting 
in carrying into the nostril a finger or some other instrument, to 
push up the fragments, while with the fingers of the other hand they 
are coaptated from without. This reduction is easier during the first 
few days than later ; nevertheless, to succeed in it, a certain amount 
of force must be employed. Hippocrates reproves the timidity of 
the surgeons of his time in regard to this, and that of the patients 
themselves, who would pay so dearly to avoid any deformity, and yet 
would not consent to what was necessary. These reflections, old as 
they are, are not the less applicable in our own times ; and I have 
seen several fractures of the nose, the deformity from which testified 
to all eyes either the surgeon's fault or the patient's indocility. 

The reduction accomplished, Hippocrates covered the nose with a 
glue made of flour from March wheat, which was regarded as prefer- 
able to any other ; and if this was not sufficiently adhesive, there was 
mixed with it some very finely powdered olibanum, or a little gum. 
The object would seem to have been to fasten the nose to an exterior 
mould solid enough to keep it in form. In order more effectually to 
hinder the giving way of the fragments, there was placed within 
each nostril some charpie, or some analogous material, wrapped in 



A TREATISE ON FRACTURES. 297 

linen or sewed up in morocco ; this was very flexible and soft. Sin- 
gularly enough, these foreign bodies were only used in fractures of 
the lower portion of the nose; it was thought that in fractures toward 
the root their presence would be unendurable. Hippocrates would 
also have had the patient use sufficient firmness to keep his own fin- 
gers applied over the nose, so as to maintain coaptation ; or if he 
could not, that it should be done for him by a woman or a child; and 
he says that he has never seen a fracture of the nose which could 
not be perfectly united by these means. In ancient Greece, where 
beauty even in the male sex was in a manner worshipped, we can 
understand that such precautions might have been observed ; in our 
day certainly few patients would submit to them, and they are passed 
over in silence by all modern surgeons. We may easily imagine, 
however, a case of fracture of the nose occurring in a woman proud 
of her beauty, in which they would not be without value. 

Lastly, if there were any tendency to lateral deviation in the nose, 
it was attempted to keep it in place by means of strips of leather 
smeared with glue, like our adhesive strips. 

After the time of Hippocrates, the idea was conceived of placing 
in the nostrils, instead of charpie, quills wrapped in some soft sub- 
stance ; Celsus makes mention of them. Paulus iEgineta speaks of 
another apparatus applied on the outside by some surgeons, in com- 
pound fractures, to prevent exuberance in the granulations ; it was 
simply a leaden cap fitted to the nose. 

I have dwelt thus carefully on the therapeutics of the ancients, 
because the moderns have merely followed after them, not even meet- 
ing the indications so completely. The modifications made in the 
apparatus have been unimportant. Avicenna substituted for wheat- 
glue that from fishes, or even strong glue, glutinum eorii vaccini ; 
Albucasis used flour and white of eggs, etc. As to the tubes intro- 
duced into the nostrils, Lanfranc made them of wax, mastic, and 
dragon's-blood, like bougies ; A. Pare preferred them made of gold, 
silver, or lead ; Boyer recommended them of india-rubber, kept in 
the nostrils by charpie placed around them like a tampon. 

These means have not, however, met with universal favor. J. L. 
Petit rejects them altogether, on the ground that more force is neces- 
sary to re-displace the bones after reduction than to reduce them ; 
and asserts that those who invented them had never reduced one of 
these fractures. 

I apprehend that J. L. Petit has here relied too blindly on his own 
experience, undervaluing that of others. Marchetti relates the case 
of a merchant of Padua who, by a blow with a large piece of wood, 
had the bones of the nose reduced to fragments as small as grains of 
wheat; he says that he kept them up first with a tent, and after- 
wards with a quill ; and still later, to favor the cicatrisation of the 
soft parts, with a leaden canula. Saviard treated a young man who 



298 A TREATISE ON FRACTURES. 

had a wound of the nose, with fracture, and such great depression 
of both bones that their lateral portions, where they joined the as- 
cending processes, were more prominent than their inner edges; the 
bones were likewise so detached at the sides and from one another, 
that thej could easily have been extracted with a pair of forceps. 
He thought proper to support them by means of hollow tents, and in 
fifteen days the patient was cured without deformity.* 

These canulas are generally fixed by means of bands going to the 
cap of the patient. Brambilla has represented an apparatus, recom- 
mended also by B. Bell, consisting of two metallic tubes, each sup- 
ported on a slender flat stem ; these stems are fastened to a metallic 
plate applied over the upper lip, this again being retained in place 
by means of two bands tied behind the head. A. Dubois resorted, 
in a difficult case, to an apparatus still more complicated, but of 
greater efficacy. 

This was composed of a semicircular metallic plate embracing the 
face from one temple to the other, passing over the upper lip, and 
jointed with another which went round the occiput. Two bands, 
passing over the head and nape of the neck, kept these two semi- 
circles at the proper height; and lastly, upon the anterior semicircle, 
above the lip, was fixed a fork, having two rounded, blunt tines, suit- 
ably covered, and intended to enter the nostrils, one going on each 
side of the septum. This fork being hinged on, and moved to and 
fro by a screw, tended to raise up the nasal bones as much as was 
required, while a free passage was maintained for the respiration. 
The use of this machine was always successful, f 

Here, as in everything else, we are to be governed by the indica- 
tions ; if there is no danger of displacement, I have already said 
that we are not to interfere ; if there be any tendency that way, the 
use of canulas or of Dubois' apparatus becomes indispensable. 

It is not only fractures with depression which must be thus kept 
in place, but sometimes also fractures with lateral deviation. M. 
Royere relates an instance in which he was obliged to resort to a 
special machine. An officer, twenty-four years old, having fallen 
from a height of about four metres, [about four and a half yards,] 
on the right side of his face, sustained a compound comminuted frac- 
ture of the nasal bones, with deviation of the fragments toward the 
left side. M. Prat, surgeon-major, performed reduction and applied 
a compressing bandage ; but this bandage soon became relaxed, and 
then the displacement at once recurred. On the tenth day, the 
wounds had cicatrised, but the tendency of the nose to deformity 
persisted. M. Royere devised an apparatus composed of a curved 
iron band, kept applied to the forehead by means of straps ; from 

* Marchetti, Sylloge Obs. medico-chir. rariorum, obs. 28 ; Saviard, Recueil 
cPobserv. chtrurgicales, obs. 107. 

f Gerdy, Traite des bandages, second ed., p. 468. 



A TREATISE ON FRACTURES. 299 

this there came off a branch with a well-padded plate at its extre- 
mity, which plate acted on the left side of the nose, pushing it over 
to the right. The nostrils were stuffed with charpie during the ap- 
plication of this machine, and consolidation occurred in forty days.* 

I do not know how far such an apparatus might become essential ; 
and I am strongly inclined to believe that if adhesive strips, not 
liable to relaxation, are insufficient, the application of a leaden cap 
exactly fitted to the nose would be at once the simplest and surest 
remedy for lateral deviations. 

So much for displacements. Let us now say a word concerning 
complications. Emphysema will disappear of itself, and requires no 
treatment. Hemorrhage may be combated first by the usual means, 
cold lotions, or applying some cold body between the shoulders. 
Raising the arm up, as advised by M. Negrier, was once successfully 
used by M. Pangue. A young man had been thrown down with his 
face to the ground, and presented a fracture of the nose with copious 
bleeding. Cold lotions having failed to check the latter, M. Pangue 
made him raise his arm up perpendicularly ; the hemorrhage ceased 
immediately, and did not recur, f 

The complication of a wound is but trifling ; if the fracture is com- 
minuted, we must accomplish as much by the first intention as pos- 
sible, and not remove any splinter until it is entirely separated. If 
an abscess occurs near the fracture, the rule laid down by J. L. Petit 
is to open it through the mucous membrane, and to make no incision 
in the integuments except in case of absolute necessity. 

When the fracture has united with deformity, it is impossible to 
correct the deviation of the bones ; but we may sometimes do this in 
the case of the cartilages. M. Dieffenbach had to treat such a de- 
formity resulting from a fall ; the nose was so displaced as to lie 
against the cheek, one nostril being upward and the other downward. 
He passed a tenotome under the skin, outside the nostril, divided the 
alar and dorsal cartilages at their junction with the bones, then did 
the same on the other side and in the septum, so that the cartilagi- 
nous part of the skeleton of the nose was perfectly movable, and 
could be brought back to its proper place. The cure is said to have 
been perfect. J Admitting some little exaggeration in regard to the 
result, this operation is none the less ingenious, and would afford a 
valuable resource in case of need. 

§ IV. — Fractures of the Upper Maxillary Bones. 

These fractures, which are very rare, and have hardly been at all 
studied until the present time, offer numerous varieties, differing 

*RecueU de Mem. de mtd., chir., et pharm. militaires, tome viii, p. 286. 
t Journ. de rne'decine et de chir. pratiques, 1843, p. 423. 
X Gazette des Hopitaux, February 22, 1842. 



300 A TREATISE ON FRACTURES. 

much in gravity. If a piercing or contusing instrument breaks at 
anv point the outer wall of the maxillary sinus, the fracture hardly 
adds at all to the trifling danger of the wound of the soft parts; such 
perforations are sometimes made intentionally by the surgeon. When 
in drawing a tooth the wall of the alveolus is broken, it is an affair 
of no more moment ; but it is otherwise when a blow or severe pres- 
sure from without detaches a portion of the alveolar arch, drives in 
one or both of the maxillary bones, and displaces at the same time 
nearly all the facial bones. 

When a fragment of any size has been detached from the alveolar 
arch, it is important to keep it in proper position in reference to the 
rest, so that all the teeth may remain at the same level. Here we 
may apply, with some modifications, most of the dressings devised 
for fractures of the lower jaw. 

Ledran tried with success the ligature of the teeth in a man who, 
having fallen under a wagon-wheel, had had the four last molar teeth 
and the corresponding part of the alveolar arch displaced into the 
mouth and up against the palate, neither the palate nor the gums, 
however, being at all torn. The fragment was movable, working 
from side to side with the different motions of the cheeks and tongue. 
Ledran conceived of fixing the teeth by a ligature, and called in the 
dentist Capron. He fastened with a large thread the four detached 
teeth to the fifth, which was still firm, and they were thus tightly 
held. The threads came away at the end of ten or twelve days, but 
consolidation was sufficiently advanced to make them unnecessary; 
and by the thirty-fourth day the man was entirely well. I would 
add that this person had at the same time a fracture of the lower 
jaw, which was cured by the same process. 

[There was in September, 1857, in the Pennsylvania Hospital, a 
patient who had fallen from his wagon on his face, a heavy box coming 
down on his head as he lay. With excessive contusion of the soft 
parts, there was a fracture of semicircular form involving the anterior 
alveoli of the upper maxillary bones, and of course detaching the in- 
cisor teeth. The lower jaw was also broken in two places. All these 
three fractures were treated by the wire ligature, which I may men- 
tion here is commonly used in this country in all cases where the 
slightest difficulty is encountered in fixing the fragments by other 
means. The case alluded to did not do very well, the patient being 
very intractable.] 

Alix had the like good fortune in an almost entirely similar case. 
A carriage-wheel, passing over a woman's head, had driven in the 
canine and two molar teeth* of the right side, with their alveoli. 
Alix had thought of removing the fragment; but, encouraged by 
Ledran's success, he readjusted it, attached the canine tooth to the 

* [In French works on anatomy the bicuspid teeth are called lesser molars, 
(petites molaires.) ] 



A TREATISE ON FRACTURES. 301 

neighboring incisor with a loop of wire, twisting the ends with for- 
ceps ; he fastened the molar teeth in the same way, only taking care 
in each case to guard the lips from irritation by the ends of the wire 
by means of a small compress. On the twelfth day he removed the 
wire from the canine tooth, on the fourteenth that from the molars; 
and in three weeks the cure was complete.* 

In a similar case, Graefe gave the preference to an apparatus 
modeled upon that of Rutenick for the lower jaw; it is deserving of 
special mention. 

A curved steel spring, properly padded, is applied over the fore- 
head, and kept in place by a strap buckled around the occiput. This 
spring has at each side a hole, with a screw for making pressure; 
and a steel brace, to which it affords a point oVappui for acting 
steadily on the dental arch. Now these braces, descending to the 
level of the free edge of the upper lip, curve backward so as to go 
around the lip without wounding it; getting thus at the dental arch, 
they again curve so as to apply themselves to it. But as the pres- 
sure of the braces should have the effect of keeping the detached 
teeth in proper relation with the rest, a silver trough duly padded is 
made to fit over both to a sufficient length ; and upon this trough the 
braces exert their pressure. It is easy to see how, by altering their 
height as regards the spring over the forehead, the pressure may be 
regulated to the right degree, f 

The simultaneous driving in of both bones cannot occur without 
numerous disjunctions of the sutures, or else fractures, of the facial 
bones. I know of but one case, which was observed by Wiseman; 
and he encountered such unheard of difficulties in replacing and 
maintaining the bones in position, as to give the case a peculiar in- 
terest. 

A little boy eight years old had received on the middle of his face 
so violent a blow that he had seemed at first dead, and afterwards 
lay in a prolonged coma. " When I saw him," says the author, "he 
presented a strange aspect, having his face driven in, his lower jaw 
projecting forward; I knew not where to find any purchase, or how 
to make my extension. But after a time he became sensible, and 
was persuaded to open his mouth. I saw then that the bones of the 
palate were driven so far back that it was impossible to pass my 
finger behind them, as I had intended; and the extension could be 
made in no other way. I extemporised an instrument curved at its 
extremity, which I engaged behind the palate, and having carried it 
a little upward, used it to draw the bone forward, which I did with- 
out any difficulty; but I had hardly withdrawn the instrument when 
the fractured portions went back again. I then contented myself 

* Ledran, Obs. Chiruryicales, tome i, obs. 3 ; Alix, Observata Chirurg., 
Altenburg-, 1774, fasc. i, obs. 11. 

f See Richter's Atlas, Tab. vi, fig. 4. 



302 A TREATISE ON FRACTURES. 

with dressing the face with an astringent cerate, to prevent the afflux 
of the humors; I likewise prescribed bleeding; and some hours af- 
terwards, I bad an instrument better constructed to reduce the large 
mass of displaced bone to its proper position; I had it held by the 
child's hand, by that of its mother or of an assistant, each for a 
certain time; nothing else was done. Thus by our united attention, 
the tonicity of the part was maintained; the callus was developed, 
and in proportion as it became solidified, the parts became stronger, 
the face assumed a good appearance, certainly better than could have 
been hoped for after such marked displacement; and the child was 
entirely cured." 

It would be more convenient, in such a case, to fix the brace in 
front of a sort of mask sufficiently removed from the level of the 
face, cut for instance like the visor of a helmet or a fencing mask. 

I have found likewise but a single case of depression of one of the 
upper maxillary bones; it will be seen that this could not occur 
without disjunction of the median suture, and fractures at various 
other points. The mobility was however much less than in Wise- 
man's case; and nature at length made the reduction almost with- 
out assistance. This case, which is also a very curious one, is due 
to M. Simonin, of Nancy. 

A carpenter, twenty-one years old, having fallen from a height of 
two stories, presented, besides fractures of the arm and leg, and a lux- 
ation of the clavicle, the following condition of the face : — Simple 
fracture of the nasal bones, loosening of the incisor teeth from the 
alveoli above and below, separation to about nine millimetres of the 
upper maxillary and palate bones in their median suture, depression 
of the entire left side of the face without any alteration of the soft 
parts; besides a vertical fracture without displacement, near the 
symphysis of the lower jaw. There were no symptoms of concus- 
sion of the brain. A pair of forceps being introduced under the 
nasal bones with the right hand, they were pried up, while coapta- 
tion was accurately made with the left hand; the approximation of 
the upper maxillary and palate bones was attempted by means of 
lateral pressure, ligatures being also placed on the upper incisor 
teetli ; but these teeth were so much loosened that they soon fell out; 
of the other fractures I shall say nothing. At the tenth day the in- 
ter-maxillary suture began to close; by the thirty-third day, the 
fractures of the nose and lower jaw were united without deformity, 
and the reunion of the suture along the palatine arch was complete; 
only the left upper maxillary bone remained slightly depressed, not 
however so as to interfere with either deglutition or talking; the 
other fractures also became firm subsequently.* 

A still more severe blow might crush or carry off a part, or even 

* Edm. Simonin, Decade Chirurgicale, Paris, 1838, obs. 9. 



A TREATISE ON FRACTURES. 303 

nearly all the facial bones, but not without proportional damage to 
the soft parts. It is generally large bodies driven by some explo- 
sive force, as balls or shells, which produce such fearful injuries. 
Larrey and Dupuytren have given instances of this; but they are 
more rarely seen caused by common blows; and in this respect I 
know of no case comparable to the following one, which I had occa- 
sion to examine a long time after the injury. 

A young boy received in the middle of his face so violent a kick 
from a horse, that the nasal, upper maxillary and palate bones were 
greatly comminuted, and the integuments contused and torn. A 
cure was obtained, but with singular deformity. The nasal bones 
were destroyed; the anterior portion of the alveolar arch, and most 
if not all of the vault of the palate, had likewise disappeared. He 
had no nose nor mouth ; the two lips being fastened together by a 
thick and firm cicatrix, the chin was continued up to an oval open- 
ing, formed between the two ascending processes of the maxillary 
bones as high as the frontal. By this one opening the patient 
breathed, spoke, ate and drank; when a piece of bread was put 
into it, the tongue was seen to come up, and to carry it down to the 
molar teeth, which performed their functions very well. 

[A man was brought to the Pennsylvania Hospital in the fall of 
1855, who had had his head caught between a hoisting machine 
worked by steam, and the floor, as he was looking over the side of 
the platform of the machine. The face was separated, bones, soft 
parts and all, from the cranium, as far back as the sphenoid bone ; 
a ghastly gash across the face, with the curious falling of all the 
features away from the forehead, was the principal external sign. 
He died of the shock, in a few hours.] 

Lastly, there is another cause of fracture of the upper maxillary 
bones, which acts from within outward ; it is the firing of a pistol 
into the mouth with a view to suicide. Nothing presents greater 
variety than the effects so produced; but this is not the place to 
enumerate them. I shall mention however the observation of Hernu, 
as an instance of a very singular fracture. The charge of the pistol, 
consisting of two balls, had made a considerable opening about the 
middle of the hard palate; the two upper maxillary bones were 
separated, not only from one another, but also from the nasal and 
malar bones. All these parts were movable ; but the only percep- 
tible deformity consisted in a prominence made by the inner angle of 
the malar bone on the right side. The lower jaw was also fractured. 
An attempt was made to overcome the projection of the malar bone; 
but, although the accident had occurred only three days before, it 
was impossible to accomplish it. The only dressing used was a strip 
below the nose, to keep the upper maxillary bones together as much 
as possible. On the twelfth day, a small splinter was detached from 
the palatine arch, after which the perforation of the arch became 



304 A TREATISE ON FRACTURES. 

much contracted; by the fiftieth day the maxillary bones seemed 
united, and there remained no other external trace of the frightful 
destruction of parts than the enlarged nose and the prominence of 
the right malar bone.* 

In compound fractures of the upper jaw, there is one principle 
which surgeons cannot too carefully bear in mind ; this is, that all 
splinters, however slightly adherent, should be scrupulously pre- 
served, as they become reunited with wonderful facility. This re- 
mark was made by Saviard ; Larrey has strongly insisted on it;f 
and we have seen that M. Baudens, who so much urges the extraction 
of splinters, has likewise made a special exception of these cases. 

* Journal de Chirurgie, Desault, tome iii, p. 236. 

f Saviard, loc. cit.; Larrey, Clznique chirurg., tome v, p. 94. 



CHAPTER III. 

OF FRACTURES OF THE LOWER JAW. 

These, although more numerous by themselves than all those of 
the other facial bones together, are however not very frequent, since 
during eleven years but twenty-seven cases presented themselves at 
the Hotel-Dieu. The excess of male cases is at least as marked as 
in fractures of the nose ; thus, of those twenty-seven, there was but 
one woman. As to age, the youngest was fourteen, the oldest fifty- 
seven years ; as to the season, two-thirds of the cases occurred in 
the summer-time, viz., from April to September. 

A good many varieties of this fracture are recognised. M. Gariel 
has proved by an autopsy the existence of a fissure on a level with 
the dental canal, involving but part of the thickness of the bone.* 
Fractures of the alveoli, so commonly caused in the extraction of 
teeth, are usually of small importance ; fractures of the rami are 
very rare. To tell the truth, I know of no case of the latter but 
that of Ledran, which was in a child of ten or twelve years ; here 
the kick of a horse produced a fracture of the body of the bone, and 
another at the angle on the same side, extending obliquely from the 
root of the coronoid process to the neck of the condyle ; there was 
so little displacement that this second fracture was only detected at 
the autopsy. f But the two great varieties which it is particularly 
important to recognise are those of the body of the bone, and those 
of the neck of the condyle. 

§ I. — Fractures of the Body of the Bone. 

The causes of these are nearly always direct, such as a fall on 
the chin, or a blow given upon the bone ; a cause not unfrequently 
mentioned by observers is the kick of a horse on the front of the 
jaw. I have seen this bone broken in a young girl by a blow with 
the fist. We must, however, recognise an indirect cause, when vio- 
lent pressure like that of a carriage- wheel tends to force together the 

* Bulletin de la Soc. Anatom., 1835, p. 24. 
f Ledran, Obs. Chirurg., tome i, obs. 8. 

20 (305) 



306 A TREATISE ON FRACTURES. 

two sides of the bone; it does not need any excessive force to pro- 
duce a fracture by this mechanism, as may be ascertained upon the 
dead body. Lastly, when a person fires a pistol into his mouth, the 
sudden development of gas is sometimes powerful enough to fracture 
the lower jaw; as took place in Hernu's case, before quoted. M. P. 
Bei aid saw a fracture of the symphysis, resulting from the firing of 
a pistol loaded only with powder. 

Most commonly the bone is fractured in but one place; sometimes 
it gives way at several points ; comminuted fractures are more rare, 
and hardly occur at all except from gunshot wounds. As to direction, 
the fracture is sometimes vertical, and sometimes oblique ; if the latter, 
according to Boyer, it usually passes downward and backward. But 
an important point to be noted is that very often the fracture divides 
the thickness of the bone obliquely; generally the obliquity is at the 
expense of the inner face of the posterior fragment, and the outer 
face of the anterior. (See Fig. 14.) This circumstance, which has 
hitherto been unnoticed, gives us the key to a good many displace- 
ments. 

Can fracture occur at any point in the body of the bone ? This 
question would seem a very strange one, had not Boyer stoutly main- 
tained that the solution of continuity never took place just at the 
symphysis. Nevertheless, Hippocrates had pointed out this form of 
fracture with great precision, and modern experience confirms that 
of ancient times. Rouyer de Mirecourt ascertained that the sym- 
physis was divided in a laborer whose jaw was affected with triple 
fracture ; it was separated so exactly in the median line, that the 
two first incisors were not even loosened. Chollet has published an 
analogous case ; I have before quoted that of M. P. B£rard. M. J. 
Cloquet has put an end to all doubt by demonstrating a division of 
the symphysis upon an anatomical specimen ; MM. A. B^rard, Lis- 
franc, Leloutre, Bush, Houzelot, and Legros, have seen similar in- 
stances ;* and lastly, I shall presently mention one observed by 
myself. 

The distinctive phenomena of these fractures are pain, deformity, 
swelling, increased salivation, loosening of the teeth, and finally 
some symptoms due to lesion of the inferior dental nerve. 

The only one of these phenomena which is constant is the pain. 
Often slight, but sometimes excessive, it is increased by the volun- 
tary raising or lowering of the jaw, by pressure at the seat of frac- 
ture, by pressure at both angles of the bone, or by any manipulation 
which displaces the fragments. 

The subject of displacements in fractures of the lower jaw has 

* See Journ. GCn. de Mtdecine, tome lxiii, p. 4, and tome lxvi, p. 80 ; Revue 
Medicate, 1824, tome iv, p. 465; Diet, de Medecine en 30 vol., art. Mdchoire; 
and Houzelot, TJiese inaug., Paris, 1827. 



A TREATISE OX FRACTURES. 307 

been discussed in various ways and with different conclusions, but 
always with the idea of the entire sufficiency of muscular action for 
their production; in regard to this there have been theories put forth 
by J. L. Petit, Boyer, Kibes, and Houzelot. I shall not stop to dis- 
pute these, but shall merely present the results of the facts. 

Quite often there is no perceptible displacement. I have myself 
three times seen this, especially in the case before mentioned as 
caused by a blow from the fist ; here the fracture was at some dis- 
tance from the symphysis. Thus, then, in the first place, wherever 
the fracture may have occurred, if the periosteum be nearly or quite 
intact, there will be no displacement of any kind. 

But if the external violence has disconnected the fragments by 
tearing the periosteum and the surrounding tissues, the muscular 
action will necessarily tend to reproduce the primary displacement, 
and sometimes to add to it, according to the seat, direction and 
number of the fractures ; it must, however, be repeated, that this 
cause comes only secondarily, and cannot of itself induce displace- 
ment. 

In simple vertical fractures, without obliquity of any kind, one of 
the fragments generally rises a little, so that the teeth are not on the 
same level ; and there may be observed also a slight separation of 
the fragments toward then upper edge. Now which fragment rises, 
and which descends ? This has seemed to me to depend on the di- 
rection of the blow, which is always felt somewhat more by one frag- 
ment than by the other. An epileptic at Bicetre had in a paroxysm 
broken the jaw nearly in the median line ; a severe laceration of the 
chin, a little to the left, showed that he had fallen on that side. 
The left half of the dental arch was some three millimetres higher 
than the right; there was a slight separation between the two middle 
incisors, which did not exist at the lower part of the fracture, and 
which was sensibly increased as the jaws approached one another, so 
that the free edges of the teeth even made an angle upward. 
M. Chassaignac saw the same phenomenon in a fracture passing ver- 
tically between the first and second incisor.* It is probable that in 
a fracture seated far back, the result would be quite different; that 
is, that the fragments would separate rather as the jaw was depressed 
than as it was elevated. 

But when the fracture, although vertical, divides the thickness of 
the bone obliquely, there occurs an overlapping from before back- 
ward, and necessarily following the direction of the obliquity. Now 
since most generally, as I have said, the posterior fragment has its 
inner face bevelled off, this fragment must remain outside of the 

* Neucourt, Obs. de/rad. de la rndchoire infe'rieure ; Journal de Chv'urgze, 
1844, p. 359. 



308 A TREATISE ON FRACTURES. 

anterior ; and the greater the overlapping, the more it is displaced , 
outward. A fine example of this is seen in Fig. 14 ; it is the jaw of 
a person who threw himself from a second-story window, and died 
instantly. Among many other fractures, I distinguished this, and 
shall presently use it in the solution of another problem. I had pre- 
viously, in 1837, had an opportunity of demonstrating the mechan- 
ism of this displacement. A person was brought into my wards at 
Saint-Louis, having sustained various injuries by a wagon-wheel 
going over his body. The lower jaw was broken almost vertically 
between the canine and incisor teeth on the right side. The poste- 
rior fragment projected outwardly about six millimetres, and was 
also carried forward so that the canine tooth was five or six millime- 
tres beyond the level of the second incisor ; the chin, however, main- 
tained its normal direction. The mouth was partly open, the teeth 
slightly separated, and the two fragments nearly on the same hori- 
zontal plane. I called the attention of the pupils to this case; and 
the phenomena observed were so different from those theoretically 
described, that several of them thought there was a double fracture, 
the median fragment being drawn backward. The patient dying of 
other and graver injuries, it was ascertained that the fracture was 
single, but its obliquity perfectly explained the nature of the dis- 
placement. 

For want of attention to this obliquity, some surgeons, completely 
preoccupied with the idea of muscular action, have carried their love 
of theory so far as to contradict their own facts. M. Houzelot, for 
example, commences by proving that the posterior fragment should 
be drawn inward by the muscles ; and a little further on he records 
two well-proven cases in which this fragment was thrown outward. 
I have already said, and I repeat, that the latter generally occurs ; 
I have found but two cases in which displacement inward had been 
seen to take place : one, related by Manoury, concerned a fracture 
caused by discharging a pistol into the mouth ; * the other is given 
by M. Baudens, and will be alluded to again hereafter. 

The overlapping of the fragments is also accompanied, generally, 
by displacement upward or downward. I say generally, because in 
the instance mentioned above, as well as in the specimen represented 
in Fig. 14, this displacement is not perceptible. When it does exist, 
the posterior fragment is usually carried upward; it was so in 
M. Houzelot's two patients, and in one case observed by M. Jousset. 
But the contrary may occur ; in another patient of M. Jousset's, 
the anterior fragment was somewhat raised. f What reason is there 
for such a difference ? As in ordinary vertical fractures, this would 

* Journal de Cliirurgie, Desault, tome i, p. 8. 

f Jousset, Note sur un nouv. appar. pour le tr. des fract. de la mdchoire in- 
firieure ; Gaz. M6dicale, 1833, p. 222. 



A TREATISE ON FRACTURES. 309 

appear to me to depend upon an impulse given by the external vio- 
lence to one or the other fragment. 

As to fractures directed obliquely downward and backward, or 
downward and forward, they may occur, like others, without any per- 
ceptible displacement, or perhaps with a slight displacement increased 
by any motion of the bone. I presume, but have not had a chance 
to ascertain it, that if the fracture commences above, near the me- 
dian line, the elevation of the jaw will cause a separation as in ver- 
tical fractures. But the following case seems to prove that the result 
is the contrary when the fracture is farther back. M. Gerard had 
to treat a fracture which ran obliquely downward and backward, com- 
mencing in front of the last molar, and terminating half an inch in 
front of the angle of the jaw. The fragments were hardly separated; 
but if the patient tried to open his mouth, the anterior fragment was 
drawn up, passing a little to the right, and the last two molar teeth 
presented a separation of two lines.* If the blow is forcible enough 
to produce notable overlapping, the direction of the latter is decided 
by that of the fracture, unless the bone breaks obliquely in its thick- 
ness ; that is to say, if the fracture passes. downward and backward, 
the posterior fragment rises over the level of the other, and vice 
versa; but the existence of obliquity in the direction of the thick- 
ness of the bone will greatly modify this result. 

Double fractures are amenable to the same laws ; they present no 
displacement except that produced by the external violence. I have 
already quoted Ledran's case, of a child who had at the same time a 
fracture of the body of the bone and one of the ramus without any 
displacement. The middle fragment may also be separated from the 
others without being much displaced ; such a case was published by 
Teissier. The patient had received a kick from a horse just at the 
middle of the chin ; there was thus caused a fracture at the symphy- 
sis, and another of the right ramus ; the middle fragment was car- 
ried downward about one line — a displacement too slight to induce 
any perceptible deformity. f 

But when the middle fragment has been completely detached and 
driven in, it is unsustained by the rest of the bone, and the muscular 
action draws it backward and downward without hindrance. In a 
patient whose case is given by Lecat, one of the fractures was on the 
r right, between the last two molars, the other on the left, between the 
canine and the first bicuspid ; the middle fragment therefore com- 
prised the entire chin. \ Fig. 15 shows a case in which a part merely 
of the chin is separated ; one of the fractures is close to the left 
ramus of the bone ; the other, commencing between the two left in- 

* Revue Medicate, March, 1835. 
t Journal de Mddecine, 1789, tome lxxix, p. 246. 

X Lecat, Remarques sur une espece part, defract. de la mdchoire inf., in the 
Supplement aux Instit. Chir. d'jffeister, p. 154. 



310 A TREATISE ON FRACTURES. 

eisors, passes obliquely downward and to the right ; and moreover, 
what is remarkable, it divides the thickness of the bone in such a 
wav that in its upper half, which is to the left, the obliquity is at the 
expense of the inner face, and in its lower half, which is to the right, 
it is at the expense of the outer face. This fragment was drawn 
considerably downward and backward from the other two, and we 
shall see hereafter how and why it was that its reduction could not 
be accomplished. Finally, Fig. 16 shows a middle fragment situated 
entirely outside the chin. As far as I could judge from a careful ex- 
amination of the specimen, the anterior fracture, separating into two 
the alveolus of the first incisor on the left side, passed downward 
obliquely to within more than a centimetre of the median line ; the 
posterior one was situated about between the second bicuspid and first 
molar teeth of the same side. The injury was caused by a charge of 
small shot fired from a gun, and several grains of the shot were still 
imbedded in the callus. The middle fragment had been forced down- 
ward and backward, but also so turned that its lower border looked 
forward and to the left, and its anterior face almost directly upward; 
the two others, riding up over it, were brought toward one another 
a good deal in front, and the interval still remaining between them 
had been filled up by a sort of fibrous ligament. The callus had 
formed in this position, and therefore with a deformity of which the 
drawing cannot give any adequate idea. 

Is this turning over inward of the middle fragment owing to its 
entirely lateral position, or was it overlooked in the preceding ob- 
servations ? I cannot say. "We should notice also that the depres- 
sion seemed much more marked on one side of the chin than on the 
other, and see if further observations will enable us to generalise this 
phenomenon in fractures of this kind. 

The swelling is rarely considerable, and is usually limited to the 
point struck. Salivation hardly ever occurs except in case of con- 
siderable displacement, but may then be present to a very marked 
degree ; one of M. Neucourt's cases filled two spittoons daily. Loos- 
ening of the teeth is also much less common than we should be led 
to suppose ; in order to their being either loosened or forced out, the 
blow must impinge directly upon them. But an accident which de- 
serves more extended notice is injury of the dental nerve. 

It would appear at first as if no fracture could occur between the 
foramina of entry and of exit of this nerve, without more or less 
damage to it, nor any displacement of the fragments without tearing 
it. No one, however, had pointed out any symptom connected with 
it till J. L. Petit mentioned, among the signs of fracture of the jaw, 
very severe pain, singing in the ears, numbness of the cheek, spas- 
modic movements of the lips, all which, according to the theory of 
those times, were ascribed to lesion of the inferior dental nerve. 
Rossi has extended this list; he asserts that injury of the nerve 



A TREATISE ON FRACTURES. 311 

leads to convulsive spasms, from which he has seen the most annoy- 
ing and incurable results; and he therefore proposes separating the 
fragments if necessary, and cutting the nerve through with a narrow 
bistoury. Flajani relates also the case of a patient who, on the 
fourth day of a fracture of the jaw, was seized with fever and sub- 
sultus tendinum ; by the fifth day there was delirium, with muscular 
contractions over the whole body ; and death ensued on the ninth. At 
the autopsy, the dental nerve was found torn, and nothing abnormal 
within the skull. It is, however, very evident that these symptoms 
are those of cerebritis; and in Flajani's case especially, the blow 
was so severe that the man lay for some time insensible.* 

Boyer has avoided this mistake, and shows things under a truer 
aspect. "Although I have seen," says he, "a large number of frac- 
tures of the jaw, both simple and compound, and even from gunshot, 
I have never seen such symptoms. Once only I have observed in a 
student of surgery, who had his jaw broken in two places with severe 
contusion of the soft parts, a paralysis of the depressor anguli oris 
and depressor labii inferioris, causing slight drawing of the mouth ; 
this I ascribed to the tearing of the inferior dental nerve." M. A. 
Be'rard saw complete loss of sensibility in the corresponding lip 
in a patient with a vertical fracture, without displacement, between 
the second and third molars; it extended from the mouth to the 
chin, and from the labial commissure to the median line; this paraly- 
sis lasted only a few days.f 

Some idea of the rarity of such symptoms may be formed from 
the fact that I have been able to find no other cases recorded, and 
that I myself have never seen them. Doubtless so slight a paralysis 
of the lip would sometimes pass unnoticed among graver symptoms. 
Thus in the case before quoted, Flajani did not observe it; and in 
the fracture represented in Fig. 16, the nerve had certainly been 
ruptured, for on introducing a bit of whalebone into the dental canal 
in the posterior fragment, this canal was found open for a distance 
of some millimetres from the fracture. But in many cases, the nerve 
is protected from any stretching by the overlapping itself, and from 
any pressure by the separation of the fragments and by the space 
between the two tables of the bone. Fig. 14 affords a striking ex- 
ample of this ; I have already said that the fracture in that case was 
owing to a fall from the second story ; here the shock must assuredly 
have been very violent. The overlapping was also quite notable; 
still the nerve may be seen to be perfectly intact, by means of a notch 
which I made in the posterior fragment, and I may add that it was 
not compressed at any point in its whole extent. 

But although fracture of the jaw is rarely accompanied by symptoms 

* Rossi, Medecine Opdratoire, tome i, p. 78 ; Flajani, Collezione d'Osservazioni, 
etc., Roma, 1802, tome iii, p. 166. 
f Gazette des Bopitaux, Aug. 10, 1841. 



312 A TREATISE ON FRACTURES. 

arising from this source, it sometimes presents much graver compli- 
cations from the severity of the external violence. I do not allude 
to the presence of a wound, which is less serious here than in other 
parts of the body. Monteggia has seen a fall on the chin produce 
hemorrhage from both ears, without any fracture; such a pheno- 
menon may occur as a complication of a fracture; thus Teissier's 
patient lost a good deal of blood in this way. The brain sustains 
more or less concussion, and this important complication explains 
the exceptional mortality of these fractures. Alix relates the case 
of a young man aged 20, who broke his jaw by falling from his own 
height upon his chin. He lost his consciousness; on the third day 
he was restless and feverish, on the fourth he had convulsive move- 
ments, and on the sixth he died.* In this category come properly 
the cases seen by Rossi and Flajani, mentioned above; and lastly I 
may add, that of the twenty-seven instances treated at the Hotel- 
Dieu, there were no less than four deaths. 

Aside from this complication, which is distinct from the mere frac- 
ture, the latter is a very simple affair, and will do very well if pro- 
perly treated. The callus may even be formed without any aid from 
art; Boyer saw consolidation occur, but not without deformity, 
in a water-carrier who would not endure any dressing, nor abstain 
from either speaking or chewing when the pain did not prevent him. 
M. A. Berard relates the still more singular case of a child whose 
fracture made no progress toward recovery till the apparatus, an 
ordinary bandage, was removed, f But we must not rely too much 
on such cases as these; this fracture, like all others, requires rest in 
order to unite, and non-union of it has more than once occurred. 
Boyer, who has seen several instances of this, says that it offers very 
little hindrance in mastication; but the following case, related by 
M. Horeau, shows however that it is not always so. 

A colonel received a gunshot wound which broke the right lateral 
portion of the body of the bone, some lines from its junction with 
the ramus. A large number of splinters were extracted, and cica- 
trisation was at last obtained; but there remained a false joint seated 
between the first and second molar teeth. In the ordinary condition 
of things, these two teeth were on the same level, and they were not 
even deranged by pushing the fragments from before backward or 
from behind forward. But if the posterior fragment were raised and 
the anterior depressed, the second molar tooth was several lines above 
the level of the first. The result was great difficulty in chewing on 
this side ; consequently the food was habitually carried to the left 
molar teeth, and its trituration was neither easy or complete. The 
digestion was impaired, and although enjoying good health, the 
colonel could not take more than his habitual quantity of food with- 

* Alix, Observata CMr., fascic. i, obs. 10. 
f Diet, de Medicine en 30 vol., art. Mdchoire. 



A TREATISE ON FRACTURES. 313 

ont being made uncomfortable; and the pains thus caused sometimes 
became very violent.* 

It must be stated also that consolidation may be delayed by other 
causes. M. Neucourt quotes a case in which an abscess was de- 
veloped at the seat of a simple fracture without displacement; it 
was opened from without, but the pus made its way into the mouth 
also. Monteggia saw, after a fracture from a blow with a stick, in- 
flammation and suppuration of the entire periosteum, and hence com- 
plete necrosis resulting in death. 

This diagnosis, when there is any displacement, cannot be difficult. 
"When there is no displacement, we must try whether pressure does 
not cause pain at some particular part of the bone, and having as- 
certained this we must seek to produce crepitation by working the 
fragments in different directions. We must also make the patient 
open and close his jaws strongly, to see if either of these motions 
causes a sensible separation at any part of the alveolar arch ; lastly, 
we may as a dernier ressort press on the two angles of the bone as 
though to force them together; this manoeuvre will almost certainly 
induce severe pain at the seat of fracture, and separation of the 
fragments. 

The prognosis, when the fracture is simple and without displace- 
ment, hardly concerns anything but the duration of the treatment. 
Boyer makes it forty days, which is a little over-estimated; thirty 
days will commonly suffice ; still, however well consolidation may go 
on, it is better to wait some days, remembering that mastication re- 
quires great solidity in the jaw. When there is considerable dis- 
placement, the prognosis should be materially influenced by the 
degree of difficulty met with in reducing the fragments and keeping 
them in place. 

The reduction is generally easy. In fact, whether there are two 
or three fragments, one can always grasp them with the fingers, the 
lower edge of the bone being just under the skin, and the upper af- 
fording a still more direct hold by means of the dental arch. I have 
seen but one case in which the difficulties of reduction were great; 
but it must at the same time be confessed that they were then invin- 
cible. 

This case was the one before mentioned, of double fracture; it is 
represented in Fig. 15. The patient was admitted into the wards 
during M. Velpeau's service, and I came on duty a few days after- 
wards. The middle fragment, which was strongly drawn downward 
and backward, was easily brought forward nearly to a level with the 
other two ; but when it came close to that on the right side, it seemed 
to catch against its posterior face, as is seen in the figure, and no 
effort could disengage it. The resident physicians had failed, and so 

* Journal de Mtdecine, by Corvisart, etc., tome x, p. 195. 



314 A TREATISE ON FRACTURES. 

did I. M. Velpeau, returning two days afterwards, was not any more 
successful. Finally the patient died, and the autopsy showed the 
source of the difficulty. The right fragment, in its upper half, was 
bevelled at the expense of the external face; the middle one, at the 
part corresponding, at the expense of its internal face. A very severe 
blow, and even a double fracture, must have been sustained to drive 
this piece backward in such a way; and if we could have brought it 
forward, it could easily have been kept in place by the support given 
it by the fragment on the right side. But this bevelled edge, now 
placed in front of it, opposed an almost insurmountable obstacle to 
its disengagement; there was an overlapping of the edges of which 
one would have no idea ; and even after death we found that to effect 
the reduction it was necessary to draw the middle portion downward 
and forward, so as to carry it first below and then in front of the 
other. 

To maintain reduction, numerous means have been devised, all 
however coming under four heads: (1) bandages; (2) fastening the 
teeth together ; (3) double pressure, exerted at the same time on 
the dental arch and on the base of the jaw; (4) ligature of the 
fragments. 

(1.) Most bandages, from the two straps of Hippocrates to the 
single or double chevestre, have the same mode of action as the 
fronde, which has the advantage of greater simplicity and solidity. 

The fronde, [a bandage with four tails, the body of which being ap- 
plied to the chin, one pair of the tails is fastened at the top of the fore- 
head, and the other pair around the occiput,] invented by Soranus, and 
approved by J. L. Petit and by Boyer, acts in the first place by fixing 
the lower jaw against the upper, and secondly by pressing the fragments 
together, when they are once brought in perfect contact. It fulfils all 
the indications extremely well when there is no displacement; but it 
has the inconvenience of keeping the mouth hermetically closed during 
the entire treatment, and for this very reason causing a slight gaping 
of fractures situated in front ; of this M. Neucourt gives an instance. 
It has seemed to me that so much rigor was unnecessary, and that, 
provided the patient abstains from extended motions of the jaw, it 
would suffice to press the fragments together antero-posteriorly to 
keep them suitably at rest. I therefore content myself with applying 
over the chin and sides of the jaw a large strip of lead-plaster, mak- 
ing one turn and a half with it around the head, and directing the 
patient to speak as little as possible, especially during the first few 
days. 

Another useful precaution is to make the patient keep his bed, 
resting his head always on the occiput. M. Neucourt has observed 
that when the head is turned on the pillow, either to the right or to 
the left, a movement at the seat of fracture is made known to the pa- 
tient by crepitation, even with dressings much firmer than the fronde. 



A TREATISE ON FRACTURES. 315 

The rule is doubtless much more important in fractures accompanied 
with displacement; any inclination of the head rarely failing to re- 
produce this, while the deformity almost always disappears when the 
head is restored to the straight position. 

M. Bouisson has proposed a fronde of elastic webbing, so as to 
allow the jaw to be slightly depressed;* this bandage, which has not 
yet been tested, would perhaps be found useful in some cases, al- 
though it certainly affords less solidity than the ordinary one. This 
solidity others have attempted to increase; we find in Theodoric the 
germ of an idea subsequently brought forward by Bcettcher, which 
consists in placing a small pad on the outside of the jaw, as an exter- 
nal splint, and another below and within, to act as an internal splint. 

Theodoric added to these others, dipped in white of egg, and sup- 
ported the whole by a leather cap. But it will be seen that the 
pretended internal splint can never be anything but an inferior 
splint, and cannot serve to sustain the outer one. Perhaps the pads, 
placed on the sides of the jaw and held there by the fronde, may 
exert a somewhat greater force in separating the fragments; be- 
sides this the apparatus has no other effect than the ordinary four- 
tailed bandage. 

(2.) Fastening the teeth together dates back to the time of Hippo- 
crates; it has ever since then been done by means of the ligature. 
"With a gold wire or flaxen thread passed round below the crowns of 
the teeth nearest the fracture, these were firmly bound together, so 
as to keep them in contact and on the same level. This is a much 
more effectual means than the fronde, and capable of overcoming 
certain displacements which are somewhat obstinate. I have men- 
tioned it as successfully used by Alix and Ledran for fracture of the 
upper alveolar arch; and also in Ledran's patient for a concomitant 
fracture of the lower jaw. Other facts which I have collected, how- 
ever, forbid our placing much confidence in it in the cases under 
consideration. Bush resorted to it in a fracture just at the sym- 
physis, using the fronde also. Next day the wire had come off, and 
the displacement was as marked as before. M. A. Berard relates a 
more serious case; he had used a silver wire, well annealed, which 
was passed twice round the necks of the teeth adjacent to the frac- 
ture on each side. The approximation was perfect and the immo- 
bility complete, for some days; but before long the gums swelled, and 
grew painful; the teeth were loosened, and the removal of the wire 
became necessary. M. Chassaignac thought to avoid these evils by 
embracing with the thread four instead of two teeth on each side, 
and by putting it half-way up the crown, so as to remove it from the 
gum and prevent irritation. The case related in support of these 
idea3 is entirely conclusive. On the seventh day of a simple frac- 

* Annates de la Chirurgie, tome viii, p. 472. 



316 A TREATISE ON FRACTURES. 

ture, the Burgeon bound the teeth together with waxed hempen 
threads ; these threads were found broken on the next day. Another 
attempt was made with silk threads, and at the end of three days 
they were broken or displaced; the trial was now abandoned. On 
the eighteenth day it was resumed with a gold wire; on the fourteenth 
day afterwards the wire still held, but the gums were red and bleed- 
ing. The patient not having returned again, the subsequent history 
of the case is unknown.* 

On the whole, while useful only in cases of slight displacement, 
ligation of the teeth involves disadvantages preventing us from re- 
sorting to it except with great caution. Moreover, the teeth are 
sometimes set so close together as to render it impossible, as in a 
case cited by Bertrandi ; and it should not be thought of when the 
teeth are worn, carious, or wanting in the vicinity of the fracture. 

Guillaume de Salicet advises us to fasten together with a silk 
thread not only the teeth belonging to the two fragments, but with 
them also the corresponding ones of the upper jaw. This plan, more 
secure but at the same time more difficult than the other, would suit 
only such fractures as were farthest from the body of the bone, 
seeing that in front the teeth do not correspond in the two jaws. 

[In the United States the treatment for fracture of the lower jaw 
consists almost exclusively of bandages, the teeth being wired to- 
gether if the displacement tends to recur. The bandage most in use 
is that of Dr. John Rhea Barton, forming three ovals, one round the 
occiput, one round the face, and one round the base of the head and 
chin ; it begins at the occiput, is carried thence round the side of the 
head, and up over the sagittal suture to the opposite temple, — thence 
under the chin, up over the sagittal suture, and back again to the 
occiput, — thence around the front of the chin directly back to the 
starting-point. This is applied very firmly, and no more motion is 
allowed to the jaw than is absolutely unavoidable. We often make 
use also of a splint of pasteboard or gutta-percha, moulded to the 
exact shape of the jaw, as an aid to the bandage. The results from 
this mode of practice are very satisfactory, although in exceptional 
cases some surgeons tax their ingenuity for contrivances such as are 
mentioned in the ensuing paragraphs.] 

Lastly, in a case of non-consolidated fracture on the right side, 
with loss of substance, overlapping, and displacement upward and 
outward of the posterior fragment, the dentist Lemaire was called in 
by Dupuytren, and devised two other plans for ligation; first, to 
carry the posterior fragment inward, he united by means of a platina 
wire the wisdom-tooth in this fragment to one of the bicuspids of the 
other side; then to carry the anterior fragment forward and lessen 

* Bush, London Med. and Phys. Journal, Nov., 1822, p. 401 ; A. B6rard, 
loc. cit. ; Neucourt, loc cit. 



A TREATISE ON FRACTURES. 317 

the overlapping as much as possible, a second wire was stretched 
from the first lower bicuspid on the right side to the first upper 
bicuspid on the left; and a third bound together the two canine 
teeth on the left side. This third wire is only an application of 
Guillaume de Salicet's method; but the two others, passing from one 
side to the other not only of one but of both jaws, constitute two 
really new resources. "We may indeed derive hence a valuable idea; 
although the wires were left in place for over two months, it is not 
said that the teeth suffered from them ; only the one which passed 
transversely from one fragment to the other had cut through more 
than half the thickness of the tongue ; and as the layers first divided 
had united again as the wire went deeper, the latter became inclosed 
like a seton ; it had to be cut on each side and drawn out like a 
hare-lip pin.* 

On the whole the ligature, however applied, is liable to some nota- 
ble inconveniences. I endeavored to attain the same end in a simpler 
and surer way by embracing the teeth of both fragments in a trough, 
fixing them by means of pressure with screws. My apparatus con- 
sisted of a thin and flexible sheet of iron, capable of adapting itself 
to all the varieties of curvature of the posterior aspect of the dental 
arch. From its two extremities, and from two intermediate points, 
rose four small steel branches, which were bent twice at a right angle, 
so as to come parallel to the anterior face. This sort of open trough 
thus embraced the dental arch in four points ; and there being a 
screw at the end of each stem, the teeth could be fastened at those 
four points against the iron piece, as against a posterior splint. 
The enamel was protected by means of a bit of lead to receive the 
end of the screw. 

If. Nicole de Neubourg had already conceived an analogous idea ; 
having to treat a fracture seated between the second incisor and the 
canine on the right side, he had two little curved steel plates made, 
fitting to the anterior and posterior faces of the teeth; a small steel 
mortise embracing both the teeth and the plates, served somewhat to 
keep them in place, and by means of a screw prevented their slipping. 
I have seen this instrument at M. Charriere's; I do not know what 
its success has been, but I doubt whether it was complete. Besides, 
from the permanent curvature of the steel plates, it could fit but one 
mouth, and but one portion of the dental arch. 

These two apparatuses, like the ligature of Hippocrates, are 
intended to fix the teeth without interfering with the movements of 
the jaw ; there are others which imitate those of Guillaume de Salicet 
and of Lemaire, keeping the jaw immovable in order better to insure 
the fixation of the teeth. Muys has given a description of an instru- 
ment devised by an unknown German surgeon, for a fracture with 

* Journal Univ. des Soc. MMicales, tome xix, p. 77. 



318 A TREATISE ON FRACTURES. 

displacement of one fragment inward and of the other outward. It 
was a sort of ivory trough, receiving into its cavity four teeth, two 
of each fragment; the patient was only twelve years old, and consoli- 
dation was effected in twenty days.* Boyer recommends an analo- 
gous apparatus, consisting of a plate of cork hollowed on its upper 
and lower faces so as to receive at once the teeth of the upper and 
lower jaws. 

These instruments are all of very limited application. For those 
which work by screws, we must have to deal with full sets of teeth, 
the crowns of which must he sufficiently elevated above the gums. 
As to simple troughs, in the first place, inconvenience arises from 
the presence of a somewhat voluminous foreign body in the mouth ; 
secondly, the nature of this body, it being susceptible, cork especially, 
of becoming loaded with mucus, and liable by the end of the treat- 
ment to give out a most fetid odor; thirdly, a last but not less 
serious annoyance results from the forced closure of the mouth ; the 
use of a four-tailed bandage or of some equivalent application is in 
fact essential to the efficacy of these instruments. 

(3.) The third method, the credit of which has been given to 
Germany, had been pointed out in 1780 by Chopart and Desault, to 
whom must be restored their* incontestable priority. f When the 
fracture occupied both sides, they proposed to keep the fragments in 
place by means of dressings composed of braces of iron or steel, 
placed upon the teeth, on the alveolar border, covered with cork or 
with plates of lead, and tightened up by screws to a plate of sheet- 
iron or to other points d'appui fixed underneath the jaiv. In other 
words they sought to fix the bone by two splints, one inferior, under 
the edge of the jaw, the other superior, applied over the teeth, the 
two being held together by an intermediate branch. In 1799, a 
German surgeon, Rutenick, applied such an apparatus successfully ; 
Bush, in England, devised another in 1822; M. Houzelot made his 
in France, in 1826 ; other modifications bear the names of Kluge, 
Jousset, Lonsdale, etc. Wood, iron wire, steel, and tin, have been 
successively used. 

I once employed Bush's apparatus, modified as follows : a steel 
branch is bent below at a right angle, so as to go under the chin, and 
above, so as to pass into the mouth ; here it describes two curves, 
one around the lower lip so as not to press upon it, the other so as to 
apply itself to the dental arch. Its lower extremity is bored for a 
screw, this screw supporting a metal plate properly padded and fitting 
either to the chin or to any other part of the base of the jaw, according 
to circumstances. The fracture being now reduced, we apply over 
the adjoining teeth of both fragments a small mould of lead or silver, 

* Muys, Praxis Rationalis, decad. xii, obs. 3. 

f It is even likely that this idea belongs exclusively to Chopart, Desault 
having never again spoken of it. 



A TREATISE ON FRACTURES. 319 

on "which the upper part of the steel branch may press ; the padded plate 
is arranged beneath the jaw, and the screw, turned by a key, forces 
this plate against the base of the bone until sufficient pressure is ob- 
tained. 

In the contrivance of M. Houzelot, the connection of the two 
splints is made by a different mechanism. The stem does not curve 
back under the chin, but descends vertically, presenting in its two lower 
thirds a longitudinal fenestra ; the sub-maxillary plate has at its 
anterior part a narrow square branch which plays in this fenestra, 
and which carries at its end a screw, so that it may be fixed at any 
required height. 

These apparatuses, and others made on the same principle, can be 
used only in fractures at the anterior part of the jaw. That of Ru- 
tenick, modified by Kluge, has some spare stems for fractures seated 
far back, which make a bend in the mouth after passing the lower 
lip, skirt along the dental arch till they reach the seat of fracture, 
and then at last curve so as to press on the mould and on the teeth. 

After all, firmly as these instruments may be put on, they all tend 
to slide forward on the chin ; hence they must be confined by cords 
or bands going around the neck, and even, if need be, tied over the 
head like the four-tailed bandage, leaving, however, enough play to 
the jaw for it to be opened at will. 

Here, indeed, is the great advantage of this plan. While fixing 
the fragments more solidly than any other, it still permits the patient 
to talk, to take semi-solid food, even to chew the soft part of a piece 
of bread. But it also frequently entails some considerable inconve- 
niences ; and it is above all important for us to know what are its 
effects on the living subject. 

Rutenick invented his instrument for a lady in whom the displace- 
ment had resisted all other means ; and he was completely success- 
ful. M. Jousset likewise obtained good results in two cases; his 
second patient having got the habit, from wearing the instrument on 
the left side, of talking with the right side of the mouth, kept the 
mouth thus twisted for about fifteen days after the apparatus was re- 
moved ; this, however, was of no importance. M. Houzelot has pub- 
lished three observations of fractures treated with this contrivance. 
In the first, it was kept on for thirteen days, when an epileptic pa- 
roxysm deranged everything, and the patient, furiously delirious, 
was transferred to Bicetre. The second patient complained soon 
after its application of a very severe pain at the lower edge of the 
jaw ; there was copious salivation ; by the sixth day these symptoms 
subsided, and on the tenth the apparatus was removed ; after which 
the fragments showed no tendency to displacement. It is not stated 
why the instrument was taken off so early ; probably it was because 
of the inflammation excited by it underneath the jaw; in fact there 
was an abscess formed there, which was opened seven days after- 



320 A TREATISE ON FRACTURES. 

wards. In the third case, the apparatus was kept on for thirty days; 
here also it gave rise to an abscess at the point where the plate 
pressed on the jaw. 

We find also, in one of M. Neucourt's cases, that this apparatus 
was applied for a double fracture, with notable displacement of the 
middle portion; the reduction was well kept up, but the apparatus 
had to be taken off on the seventeenth day, an abscess having formed * 
beneath the chin. 

At all events, however, the instrument has been endured for a 
longer or shorter time, and always with some good results. Some 
patients seem more sensitive, whether from the edge of the bone 
being sharper, or from the skin covering it being thinner. For some 
reason or other, the patient for whom Bush had his instrument made 
was unwilling to wear it for more than a few days. Rutenick's ap- 
paratus was not endurable for any greater length of time in a double 
fracture in a young man of twenty.* I myself tried Bush's appa- 
ratus on an epileptic at Bicetre, for a simple fracture with very slight 
displacement, and the pain was so great that I had to take it off. I 
had at first thought these symptoms due in some degree to the too 
early application of the instrument ; but in my patient I waited scru- 
pulously till all inflammation had subsided, and in M. Houzelot's 
second patient the apparatus, though not put on till the sixth day, 
nevertheless gave rise to abscess. 

There is therefore a radical defect in these contrivances, which is 
that they exert too direct a pressure upon a sharp bony ridge. Per- 
haps it may be required, in order to protect the integuments from 
all pressure, to pass steel points through them, as I have had to do 
for fractures of the leg. It would be necessary to act upon each 
fragment with two points, separated by two or three millimetres, so 
as to catch the bone and prevent its slipping ; such points could be 
easily adapted to the sub-maxillary plate of Bush or of M. Houzelot. 

I must not omit to notice a very singular fact regarding one of the 
cases whose history is related by M. Houzelot. After the apparatus 
had been kept on for thirty days, the teeth of the upper jaw corre- 
sponding to the plate were below the level of their neighbors by 
about a millimetre ; but ten days afterwards they were on the same 
level. It is very singular that this effect should have occurred in 
the upper jaw only ; and no other instance of it has been observed. 

(4.) The ligature of the fragments has been employed but once, 
by M. Baudens, in the following case. A chasseur, by a fall from a 
horse, broke his jaw at the second molar tooth on the left side; the 
fracture was complicated by a wound and by splinters, and was ob- 
lique downward and forward ; the posterior fragment, strongly drawn 

* Michaelis, Beschreibung, etc. ; Journal de Chirurqze, by Graefe and Wal- 
ther, 1823. 



A TREATISE ON FRACTURES. 321 

inward, lost its place as soon as it ceased to be held. M. Baudens 
passed a ligature round the fragments, and sutured the wound. No 
bad symptom ensued, and the ligature was withdrawn on the twenty- 
third day, leaving the bone regularly and completely united. This 
certainly is an extreme resource, and should not be employed except 
in case of necessity ; but in oblique fractures at least its efficacy is 
beyond doubt, and this first trial answers all the objections which 
would not fail to spring up in theory. 

The process is, besides, very simple. M. Baudens used a needle 
eight centimetres in length, flexible in the middle, so as to take 
any required curvature, and pierced with two eyes, one near the 
point, the other close to the head ; the ligature, formed of six or 
eight ordinary threads, was passed through both eyes at once. The 
fracture being reduced and so maintained with the left thumb and 
forefinger, the operator passed the needle under the lower edge of 
the jaw, following the inner face of the bone, and bringing out the 
point between the gum and the neck of the tooth, so as to be able 
to draw out by the mouth the end of the thread engaged in the eye 
near the point. The needle being now withdrawn by the same track, 
was directed along the external face of the bone, emerging in the 
same way by the side of the gum, and this time withdrawn through 
the mouth ; so that the loop of the ligature surrounded the base of 
the jaw, and the two ends could be tied in a double knot above the 
teeth. A needle having one eye near its point would accomplish the 
end as well, and would not even need to be withdrawn through the 
mouth, which would be the most difficult part of the operation in a 
fracture seated somewhat far back. 

Such are the plans hitherto proposed ; some useful only in the 
simplest cases, others multiplying our resources in proportion to 
our difficulties. Certain circumstances sometimes prevent their 
employment. If the teeth are wanting in the vicinity of the frac- 
ture, we may, if necessary, contrive some artificial substitute for 
them. 

Duverney has suggested that the jaw might be broken when com- 
pletely destitute of teeth. This case seems never yet to have pre- 
sented itself; but if none of the methods mentioned could be used, 
the suture of the fragments would be our only resource. 

"When a tooth has been loosened or displaced by a fracture, what 
is to be done with it ? Mr. B. Bell advises its extraction ; Heister 
and Duverney prefer making an attempt at its preservation. This 
would certainly be safest ; there will always be time enough to extract 
if circumstances demand it. 

I know of but two cases in which art has interfered to procure 
consolidation of ununited fractures of the jaw. Physick succeeded 
by passing a seton between the fragments ; I have not been able to 

21 



322 A TREATISE ON FRACTURES. 

procure any further details of the case.* Dupuytren resected one of 
the fragments and rasped the other; but he had to encounter very 
great difficulties in keeping them in contact; and it was for this very 
case that Lemaire devised the triple ligature before described. The 
patient is said to have been completely cured, but at the expense of 
long-continued and cruel suffering. The suture of the fragments 
would have so simplified the matter, that in a similar case I would 
not resort to any other method. It would be the same also in 
recent gunshot fractures, with destruction of the soft parts and obsti- 
nate displacement of the fragments ; for instance, no one can ex- 
amine Fig. 16 without being convinced that the suture would have 
been the only and at the same time the all-sufficient means of pro- 
ducing coaptation. 



§ II. — Fractures of the Neck of the Jaw-Bone. 

This fracture is excessively rare, and for my own part I have 
never seen it. It appears to have been observed by Soranus, after 
which no more mention of it occurs until the time of Desault, and I 
know at present of but eight published instances. 

The cause ascribed in both of Desault' s cases was a fall on the 
chin. In a patient treated by Ribes, the blow seemed to have fallen 
on the corresponding side of the jaw, part of the lower lip and of 
the cheek having been at the same time divided ; and in another 
case, reported by M. A. Be'rard, the patient had fallen from a height 
of twenty-five feet, fracturing the malar bone and the petrous por- 
tion of the temporal on the right side, along with the neck of the 
corresponding maxillary condyle, the blow having likewise fallen on 
this side.f Here, then, are at once two well-established orders of 
causes. 

[A man was brought to the Pennsylvania Hospital in the fall of 
1855, who had been injured by the premature explosion of a blast ; 

* [The case was published in the Philadelphia Journal of the Med. and 
Phys. Sciences, vol. v, p. 116; being reported by the patient. The lower jaw 
was broken (it is not stated in what way) on the 29th of March, 1820. The 
fracture was double, — transverse on the right side and oblique on the left. Se- 
duction of the fragments on the left side was very difficult, and its maintenance 
still more so. An improperly applied compress subsequently bore the anterior 
fragment too much inward. A false joint ensued, with injury to digestion, baro- 
metric pains, etc. In November, 1820, Dr. Physick was applied to, and removed 
the neighboring teeth, with some little relief. Being again consulted on the 
27th of April, 1822, he passed a seton, which induced suppuration and a dis- 
charge of bits of necrosed bone. July 27, the seton was removed, and at the 
time of the report the jaw was almost entirely healed.] 

t Mem. sur la fracture des condyles de la mdchoire; Ouvres chir. de Desault, 
tome i, p. 47 ; Ribes, Diss, sur V articulation de la mdchoire infe'rieure, These 
inaug., Paris, an xi, [a.d. 1803;] A. Berard, Gaz. des Hopitaux, Aug. 19, 1841. 



A TREATISE ON FRACTURES. 323 

among other injuries, which proved fatal, he had a fracture of the neck 
of the right condyle, diagnosed during life, and verified by the post- 
mortem examination.] 

It seems also that to each of these causes there corresponds a dif- 
ferent lesion. In the two cases from falls on the chin, the fracture 
of the neck was simple and uncomplicated ; after a blow received on 
the side of the jaw, the fracture of the neck was accompanied by one 
of the body of the bone, on the opposite side. 

M. Houzelot has quoted a case yet more complicated, where, in 
consequence of a fall from a height, there were found fractures of 
both condyles, of both coronoid processes, and of the symphysis. 

There remain two instances given by Kibes, and another by Bichat, 
in which the cause is not stated ; two were simply fractures of the 
neck ; the other a fracture at once of the neck and body, so that 
these two forms would seem equally frequent. 

Desault, or rather his pupil Bichat, notes as symptoms of this frac- 
ture, when simple, pain, difficulty of movement, crepitation ; ine- 
quality, sometimes perceptible, in the region of the fractured con- 
dyle ; the facility of burying it in the zygomatic fossa by pushing it 
forward ; its not sharing in passive motion of the rest of the jaw ; 
and lastly, an almost constant displacement, the condyle being car- 
ried forward and upward, the body of the bone remaining behind, 
and the two fragments being separated by an interspace more or less 
perceptible. The two cases reported by him do not afford the details 
necessary in order to appreciate the value of this description ; we 
learn only that in one case there was. preternatural mobility at the 
seat of the fracture, and in the other an almost entire inability to 
move the jaw. 

We must here distinguish between cases in which the fragments 
remain impacted, without displacement, or with a partial and very 
slight displacement, and those in which they become quite loosened 
from each other. In the first case, there is indeed pain, crepitation, 
and some little deformity, but no notable mobility between the frag- 
ments ; in the second case, crepitation is apt to be wanting by reason 
of the displacement, and the body of the bone, separated from its 
condyle, presents at the seat of fracture an abnormal mobility. 

This mobility was observed by Soranus, who even makes it a means 
of diagnosis between fracture and luxation : Fractura quce fit ad 
rostra maxilles raphani modo, dignoscitur quod moveatur dum ope 
digitorum adducitur ; luxata vero immobilis sit usque ad se- 
junctionem. 

There is in fact, when the fragments are separated, a phenome- 
non, omitted by Bichat, but pointed out by Ribes, which might lead 
to a suspicion of luxation of one of the condyles, viz., that the chin 
is drawn to one side. But in luxation, it is carried to the side oppo- 
site the lesion, while in fracture it deviates to the same side. This 



3'24 A TREATISE ON FRACTURES. 

ifl because the corresponding half of the bone does not merely rest 
posteriorly, but is drawn at once backward and upward by the unop- 
posed action of the muscles. 

The displacement of the condyle, induced by the cause of the 
fracture, increased and maintained by the action of the external pte- 
rygoid muscle, is a main point in the history of this fracture. The 
condyle itself remains in relation with the glenoid cavity, but the 
pterygoid muscle makes it execute a movement of rotation, carrying 
the fractured neck upward, forward and inward, so that the frac- 
tured surface of the inferior fragment is in relation only with the 
posterior surface of the neck and of the condyle. 

When the fracture is double, the fragments may remain in con- 
tact, just as when it is single ; or they may undergo the same dis- 
placement as occurred in the two patients of Babes ; or the middle 
fragment by itself may be carried inward, as was seen by M. A. 
Be*rard. In his patient, the double fracture had not at first in- 
volved any notable displacement ; but on the fifth day there came 
on a convulsive trembling, which led to a very considerable displace- 
ment inward of the middle fragment; death took place two days 
afterwards. 

The diagnosis is generally easily deduced from the symptoms 
pointed out ; we can, moreover, explore the fracture at once exter- 
nally and internally, by passing a finger into the mouth. 

Simple fracture, without displacement, may unite without any ap- 
paratus ; it is proper, however, to keep the jaw at rest by means of 
&fronde. Bichat cites a case in which, motion having been incon- 
siderately impressed on the bone, the ununited condyle exfoliated, 
and was partially thrown off. Consolidation, when favored by rest, 
is quite prompt ; in both of Desault's cases it was completed by the 
thirtieth day. 

But when the two fragments are separated, the treatment is much 
less easy. "A surgeon in Paris," says Ribes, "was called to a stu- 
dent of surgery who had a fracture of the body of the jaw-bone and 
another of the neck of the condyle ; in spite of the most assiduous 
and skilful attendance, the patient recovered with the chin drawn to 
the same side as that of the fractured condyle." 

Ribes himself had to treat, in the year II, [of the French Republic ; 
A.D. 1794,] a patient with a similar fracture on the left side; and in 
spite of all his care in applying the means then in use, the result was 
the same as in the foregoing case, the chin being twisted toward the 
fracture. 

The means proposed for reduction arrange themselves, so to speak, 
under two methods. The first, pointed out by Chopart and Desault, 
consists essentially in carrying forward the body of the bone ; some 
would at the same time raise the chin ; and different bandages have 
been devised thus to fix the jaw. Such were the means at first tried 



A TREATISE ON FRACTURES. 325 

by Ribes, which so sadly disappointed him. Bichat relates, however, 
two cases thus treated by Desault with complete success, except that 
the movements were not perfectly restored. If, indeed, the cure was 
complete, there cannot have been disjunction of the fragments, and 
therefore the manipulations and the bandage employed by Desault 
were perfectly useless. As is justly remarked by Ribes, there was 
nothing in it all which could change the position of the condyle, 
drawn inward by the muscle attached to it. 

Thus, then, the true indication, which constitutes the second and 
the only rational method, is to act at once on both fragments, but 
particularly on the condyle, to bring them back to their proper rela- 
tion. In order to do this, if the fracture is on the right side, the 
anterior part of the jaw is to be seized with the left hand and drawn 
horizontally forward, while the right forefinger is carried to the side 
and upper part of the pharynx. There we encounter first the pro- 
minence of the styloid process ; but carrying the finger forward, we 
soon come to the posterior edge of the ramus of the jaw ; and pass- 
ing along this border from below upward, we come to the inner edge 
of the condyle, which we push outward so as to engage it against the 
other fragment. This cannot be done without producing' nausea, as 
is always the case when the finger is carried into the throat ; but 
this inconvenience is but trifling. Reduction being accomplished, 
the jaw is pressed upward and backward so as to fix the condyle be- 
tween it and the glenoid cavity ; it is then closed, and retained in 
place by means of a four-tailed bandage. 

Ribes, to whom this plan is due, had occasion to apply it in the 
case of a cannonier who had a fracture of the neck of the right 
condyle with a wound of the corresponding cheek, and another frac- 
ture on the left side of the body of the jaw. The destruction of the 
soft parts gave him the idea of carrying the finger to the inner side 
of the condyle in order to replace it, which he did easily; and the 
patient recovered without deformity at that portion of the bone, 



CHAPTER IV. 

FRACTURES OF THE HYOID BONE, Etc. 

These fractures are extremely rare, and have only latterly at- 
tracted attention. The close proximity of the hyoid bone and larynx, 
as well as their arched form, expose them to the same causes of frac- 
ture; thus a hand tightly grasping the throat, or a similar force 
applied by a cord, as in hanging, might under some circumstances 
fracture the hyoid bone or the thyroid cartilage. 

§ I. — Fractures of the Hyoid Bone. 

Notwithstanding the considerable number of subjects carefully 
examined after death by hanging, we know of but two or three cases 
in which the hyoid bone was broken by the cord; and there has been 
also much difference as to the interpretation of the facts. M. Orfila 
relates the case of a locksmith aged 62, who hung vertically nearly 
half a foot from the ground, in whom the hyoid bone was found 
forced strongly backward, and fractured at the part sustaining the 
two cornua on the right side ; the greater cornu was therefore very 
movable, and could be approached close to the one on the other side. 
Ollivier (d'Angers) thinks that in this case the action of the cord 
had nothing to do with the fracture, which he ascribes to the sudden 
and violent throwing back of the head; he adds however that he 
made an autopsy in another instance, in which, although the dispo- 
sition of the cord and of the head was the same as in M. Orfila's 
case, the hyoid bone had remained intact. M. Cazauvieilh met with 
a fracture of this bone (probably of the body) in a man who had 
been hanged ; in another he saw a fracture of the greater cornu, but 
he adds nothing concerning the mechanism producing them ; in re- 
spect to this therefore science is as yet in want of facts.* 

Judging from these three cases, hanging acts chiefly upon the 
body of the bone ; it appears on the contrary that pressure on the 

* Orfila, TraiU de mCd. Ugale, third edition, tome ii, p. 423; Ollivier, art. 
Hyoide, Diet en 30 vol.; Cazauvieilh, Du suicide, etc., 1840, p. 221. 

(326) 



A TREATISE ON FRACTURES. 327 

throat by the hand of an antagonist, the thumb on one side and the 
fingers on the other, tending to force together the two cornua, affects 
those branches exclusively. MM. Lalesque, Dieffenbach and Au- 
berge have each published such a case; in the first the left cornu 
was broken, in the last two, the right. Two of the subjects were 
men of fifty-five and sixty-seven years; the other was a girl of 
nineteen.* 

The hyoid bone is usually so well protected by the jaw, that it 
easily escapes pressure or blows not given by an expert hand; thus 
in the only case of this kind which we know of, the lower jaw was 
broken also. The account is given by M. Marcinkowski. A woman 
was brought to the hospital, livid, and in a state of suffocation ; all 
that could be ascertained was that she had been thrown against a 
wall by a coach which had been overturned upon her. She died in 
twenty-four hours, and the autopsy revealed a fracture of the left 
cornu of the hyoid, the jaw also being broken on that side.f 

But another much more curious cause of fracture of the hyoid is 
muscular action, which seems placed beyond doubt by the observa- 
tion of Ollivier d' Angers. A woman aged 56 made a false step 
and fell, her head being thrown forcibly backward. At the same 
moment she heard a very distinct crack at the upper part of the 
left side of the neck; there was a fracture of the greater cornu of 
the hyoid. 

[Dr. F. H. Hamilton of Buffalo refers, in an article on fractures 
of the hyoid bone published in the Buffalo Medical Journal for 
August, 1857, to a case reported by Griinder in Schmidt's Jahrbuch, 
volume 68, in which the cause ascribed was muscular violence. He 
also quotes another, reported by Dr. Wood of Cincinnati, in which 
the injury was produced by a direct blow, received in falling down 
stairs. In the former case the result was fatal; the latter did well.] 

The symptoms are quite characteristic. This crack as the bone 
yields seems to be commonly heard, for it was spoken of by three of 
the patients above mentioned; the pain is severe, comes on imme- 
diately, and is quickly followed by very notable external swelling ; 
there is usually also slight ecchymosis. All movements affecting the 
bone increase the pain, especially those of the tongue, and more par- 
ticularly attempts to speak or to swallow. One female patient com- 
pared the pain induced by swallowing to that from a fish-bone stuck 
in the throat. In M. Lalesque's patient, the fracture being in the 
left greater cornu, the tongue seemed drawn to the right; in the 
young girl treated by M. Dieffenbach, the voice was hoarse, and re- 
mained so for a pretty long time; but these were purely accidental 
phenomena. 

* Lalesque, Journ. Hebdornadaire, March, 1833; Dieffenbach, Gazette Me'di- 
cale, 1834, p. 187; Auberge, Revue Medicate, July, 1835. 
f Gazette Medicate, 1833, p. 354. 



328 A TREATISE ON FRACTURES. 

To these symptoms are added, in some cases, crepitation, displace- 
ment, and a sensation as of splinters. Crepitation is not heard when 
the fragments are loose. Thus in M. Dieffenbach's case, slight pres- 
sure over the greater cornu pushed both the fragments inward, 
cawing evident crepitation; but as soon as the pressure was re- 
moved, the fragments resumed their place. On the contrary, in the 
two cases of MM. Lalesque and Auberge, the posterior fragment 
being separated and thrown backward and inward, no crepitation 
was felt; but the projection of the anterior fragment was easily per- 
ceived by the touch, and behind this projection a depression in which 
might be traced the displaced fragment ; lastly the finger, carried 
far back along the floor of the mouth on the side of the fracture, 
encountered at once the projection inward of this fragment; and it 
is to be noted that both observers say that they felt small splinters 
which had penetrated the mucous membrane. These splinters ap- 
pear to me to have been merely the sharp end of the posterior frag- 
ment. Doubtless it was just such a circumstance which give the 
sensation of a fish-bone to M. Ollivier's patient — a sensation which 
disappeared when the fragment was pushed outward. 

Fracture of the hyoid bone, when properly treated, is not very 
serious; its gravity depends entirely on the accompanying inflam- 
mation, unless this be carefully subdued. In Ollivier's patient, the 
inflammation was followed by suppuration, and finally by necrosis of 
the posterior fragment, which was discharged after three months by 
the fistula remaining from the abscess. This fistula afterwards closed 
readily; but there was left a hindrance to deglutition amounting 
sometimes to pain, and persisting for several years. 

The treatment should therefore essentially and promptly combat 
this inflammation, not sparing if necessary both general and local 
bleeding. But the surest antiphlogistic is the repose of the parts; 
whence the propriety in these cases of imposing silence, of limiting 
or absolutely preventing the movement of deglutition, and lastly of 
reducing and confining the fragments. 

When there is no displacement, there is doubtless no need of 
so much rigor. In his patient, Dieffenbach merely combated 
the inflammation by an ordinary tisane, without imposing silence 
or applying any dressing, and the patient recovered no less 
readily. 

But in case of displacement the indications are more urgent. To 
perform reduction, the forefinger is introduced into the mouth; the 
posterior fragment is pushed outward and forward ; while the other 
hand, from without, presses on the rest of the bone to bring them 
in contact. M. Lalesque obtained coaptation only with great trou- 
ble ; M. Auberge, on the other hand, says it was easy ; both had fol- 
lowed the same method, even to the precaution of putting a very 
firm linen compress between the teeth. I must say, indeed, that 



A TREATISE ON FRACTURES. 329 

the observation of the latter so strongly resembles the other both 
in matter and form, as to leave an unpleasant impression on the 
mind. 

Thus both had the head held slightly inclined backward; both were 
directed to observe immobility and silence; both used the oesophageal 
tube. M. Lalesque left the tube in position for twenty days ; on 
the twenty-third the tisane was swallowed without difficulty. On 
the fortieth, solid food was allowed. On the forty-seventh, the 
patient talked with ease. On the sixty-fourth day, the cure was 
complete; the finger, carried into the mouth and over the seat of 
fracture, detected a slight nodosity marking the reunion. M. Au- 
berge, without entering into these details, says only that consolida- 
tion occurred by the end of two months. 

Only one question need detain us here: this position of the head, 
with a view of producing what M. Lalesque very improperly calls 
permanent extension, — is it the most suitable? It may be said that 
by stretching the muscles and ligaments of the hyoid bone, it fixes 
it like an object drawn in two directions by stretched cords. But 
this cannot apply to the case where the head is moderately thrown 
back; and by carrying it farther back, M. Lalesque himself says 
that the hyoid is thrown forward, and that there is danger of dis- 
placement. I am inclined to believe, for my own part, that a much 
better means of preventing displacement would be to relax all the 
muscles ; and for this purpose the right posture is with the head 
inclined forward, or exactly the opposite of the one preferred by 
M. Lalesque. 

§ II. — Fractures of the Laryngeal Cartilages. 

Almost as rare as those of the hyoid bone, these fractures have 
been chiefly observed in persons who have died by hanging. Mor- 
gagni says he has sometimes seen the larynx thus fractured, and 
notes that it was always in subjects of advanced years. Remer adds 
another circumstance; he met with such a fracture in a man who 
had been hung, in whom the mark of the cord was perceptible over 
the larynx. 

We do not know the precise seat of the fracture in these cases. 
Other observations would lead us to think that the cricoid cartilage 
was affected in preference. Such a case was seen by Valsalva; 
"Weiss found this cartilage broken in several pieces, as well as sepa- 
rated from the rest of the trachea; and a third case was observed 
by M. Cazauvieilh.* 

The thyroid cartilage more readily escapes the action of the cord ; 

* MorgagnL Dz sedibas, etc., Epist. xix, No. 13, 14, and 16; Remer, Annales 
dlxygitne, tome iv, p. 171 ; Cazauvieilh, op. cit. 



330 A TREATISE ON FRACTURES. 

but it may be fractured by the hand of an antagonist pressing strong- 
ly on its two sides. M. Ladoz, in 1838, published an instance of 
this, observed in a man who had been assassinated; the neck was 
found compressed by a very thick handkerchief, forming a band 
about four fingers'-breadths wide; but it presented also lacerations 
and contusions produced with the hands and nails. The thyroid 
cartilage presented a fracture with irregular borders, nearly in the 
form of an S, fifteen millimetres long ; it extended from some lines 
below the upper border of the right half of the cartilage to its lower 
part, and from the salient angle formed by the right and left halves 
to the junction of the anterior and middle third of the right half. 
The person was only thirty-seven years old, but the whole cartilage 
was in an extremely advanced state of ossification.* 

M. Ladoz has no doubt that this fracture was produced exclusively 
by violence inflicted with the hands and nails. This mechanism is 
at least placed beyond doubt in the following case, given by M. Mar- 
jolin:— 

"Two women in the hospital having quarreled, one of them seized 
the other by the throat, and grasped her so tightly as to fracture the 
thyroid cartilage from its upper to its lower part. You may conceive 
that it was not very difficult to detect the fracture, and that there 
was no apparatus to be applied. Silence, low diet, and a small 
bleeding, were ordered, and the cure was a perfect one."f 

Lastly, Plenck is quoted by Monteggia, as having seen a case of 
this fracture resulting from a direct blow ; the neck, in a fall, strik- 
ing against the edge of a bucket, both the thyroid and cricoid carti- 
lages were broken. 

[Dr. Hamilton [Buffalo Med. Journ., Aug., 1857,) reports a simi- 
lar case observed by himself, the patient having been kicked by a 
horse. Dr. H. performed laryngotomy thirty-eight hours after the 
accident, with relief to the symptoms of suffocation; but the man 
died in about thirty-four hours, apparently from exhaustion.] 

M. Marjolin thinks that the occurrence of this fracture is favored 
by ossification of the cartilage, an opinion to which the case of 
M. Ladoz, as well as those of Morgagni, lend a good deal of proba- 
bility. 

Is fracture of the thyroid cartilage in the living subject always so 
harmless ? In Plenck's case, death occurred almost instantly, with 
convulsions, without the slightest cry, and probably by occlusion of 
the glottis. In 1823, M. Ollivier communicated to the Acaddmie de 
Medccine a case in which it was followed by suffocation, at first inter- 
mittent and afterwards persistent, till death ensued.J It is to be re- 
gretted that this case was not published with more copious details. 

* Gazette Medicate, 1838, p. 698. 

t Marjolin, Cours de Pathologie Chir., p. 396. 

X Archives Generates de Mtdecine, tome ii, p. 307. 



CHAPTER V. 

FRACTURES OF THE VERTEBILE. 

Fractures of the vertebrae are very rare ; only fourteen cases 
were treated at the Hotel-Dieu in the course of eleven years. They 
occur more frequently in men than in women, and in adults oftener 
than in other persons ; which is explained by a reference to their 
causes. 

These fractures present numerous varieties, first according to the 
region affected, and again according as they are seated in different 
portions of a vertebra. "We have to study here neither fractures of 
the atlas and odontoid apophysis, nor those of the articular apo- 
physes of other vertebrae, which we find accompanying luxations. 
Isolated fractures of the transverse processes are hardly possible 
except by gunshot, as in one of the men wounded in July, [1830,] 
who, among other lesions, had had the transverse process of the axis 
broken by a ball.* There remain fractures of the spinous processes, 
of the arches, and lastly of the bodies ; each of which demand sepa- 
rate study. 

§ I. — Fracture of the Spinous Processes. 

Hippocrates has traced the history of these fractures in a passage 
too remarkable not to be quoted entire : — 

' ; When one or more of these osseous eminences have been frac- 
tured by force, there is at the seat of fracture a deceptive depression, 
inducing suspicion of a luxation of the vertebrae forward. The pa- 
tient's attitude also increases our liability to err. For if he tries to 
bend forward he feels pain, because the skin is stretched at the seat 
of injury, and the bony fragments pierce the tissues ; on the con- 
trary, by bending backward the skin is relaxed, and the fragments 
cause less irritation. Moreover, if the hand is applied there, the 
tissues yield forward, and the spot seems empty and flaccid to the 
touch. This is what especially deceives surgeons. As to the pa- 

* Legons Orales de Dupvytren, tome ii, p. 504. An analogous observation 
may be found in Duvernev. 

(831) 



332 A TREATISE ON FRACTURES. 

tients, they recover quickly and easily; for all these spongy bones 
consolidate with rapidity." 

Modern writers have added little to this picture. Duverney, how- 
ever, reports an instance where two of the spinous processes were 
fractured without any displacement ; the fracture was only recognised 
by their mobility. Aston Key accidentally met in the dead subject 
with a proof that consolidation is not always so certain as was sup- 
posed by Hippocrates. The fracture was in the third dorsal vertre- 
bra ; the spinous process was movable, united to the rest by a com- 
plete pseudarthrosis, with ligaments, cartilages and synovia. 

Sir A. Cooper also has observed some symptoms not mentioned 
by Hippocrates. A young boy having tried to carry a heavy wheel 
by passing his head between the spokes, and resting the weight on 
his shoulders, the load proved too much for his strength, and he fell, 
doubled up. When brought to Guy's Hospital, he had the appear- 
ance of a man long affected with spinal curvature ; three or four of 
the spinous processes were broken, and the muscles detached from 
them on one side, so that the fragments had an oblique direction. 
There was no symptom of injury of the cord ; the patient recovered 
without any apparatus, with free use of the trunk and limbs, but still 
with deformity. 

This last word refers doubtless merely to the deviation of the 
spinous processes ; it is, however, to be regretted that the account 
is so scanty that we cannot even learn where the fracture was 
situated. 

I presume that most commonly this fracture is due to a direct 
cause ; a blow, a fall, or pressure. I have seen but two cases of it; 
in the first, the cause was probably a fall on the back ; in the other, 
the patient had been thrown under the wheel of his cart, which 
passed over the shoulder and the back of his neck; he died from his 
other injuries, and the autopsy showed the spinous process of the 
axis entirely separated by a fracture running downward and forward. 

[In a man who died in the Pennsylvania Hospital of injuries re- 
ceived by the fall of a derrick, besides a very extensive comminuted 
fracture of the left scapula, the spinous processes of the last two 
cervical and first dorsal vertebrae were found to be broken. These 
fractures were undetected during his life, (which only lasted four 
days,) owing to the severity of the other lesions; and were dis- 
covered after death by mobility and crepitation being accidentally 
perceived.] 

The symptoms have been sufficiently pointed out ; but it is not 
essential that the muscles should be torn, for the processes to be dis- 
placed to the right or left. Paulus JEgineta has indicated the means 
of diagnosis employed by Duverney, which was by passing the fin- 
gers over the fragment to ascertain its displacement and its mobility. 

The treatment consists almost entirely in rest. Paulus JEgineta 



A TREATISE ON FRACTURES. 3oS 

recommends extracting the fragment by means of an incision. This 
operation, thus advised in a general way, would be entirely irrational. 
The spine displaced laterally seems itself to tend to resume its posi- 
tion; Aurran convinced himself of a spontaneous reduction of this 
kind,* as I myself did in the following case. 

An attorney's clerk, aged 22, fell while drunk from a second-story 
window; he struck first on his heels, breaking both the calcanea, 
then on his buttocks and loins ; he immediately felt an acute pain at 
the lower part of the back. On examination, following the line of 
the spinous processes, we found in place of that of the twelfth dorsal 
vertebra a hollow, very painful on pressure ; this spine was displaced 
to the right, and the swelling preventing its being moved so as to 
develop crepitation, some of the pupils made just such a mistake as 
was pointed out by Hippocrates, in supposing that the whole vertebra 
partook of the displacement, the body of the bone being carried to 
the left. There was no symptom of injury of the cord ; but when- 
ever the patient moved the trunk he felt at the level of the displaced 
spine such severe pain as to elicit screams ; this pain diminished 
greatly when he was supported by the upper and lower portions of 
the trunk, leaving the middle portion entirely free. I had him laid 
horizontally, a board being put under the mattress to prevent its 
sinking in, and a cushion passed under the loins to sustain the in- 
jured part. The pain soon subsided ; by the seventh day it had 
completely disappeared, and no longer recurred on his moving. I 
would add that when he became fit to get up, we examined the spine 
carefully; the process had resumed its normal position, and its spon- 
taneous reduction occasioned no small surprise to all those who had 
satisfied themselves of its displacement. 



§ II. — Fractures of the Vertebral Arches. 

These are more commonly called fractures of the vertebral laminae, 
because among the few cases known to our science, the injury seems 
to have involved this portion of the bone in preference. But besides 
the cases being so rare, they have not been described with all the 
exactness desirable ; and a fracture seated in front of the laminae, in 
the narrow neck joining the arch to the body of the bone, would give 
rise to phenomena and indications exactly the same, so that the two 
could not be distinguished from one another. 

These fractures are caused by direct violence, and particularly by 
falls on the back. Can there be a fracture of a single vertebral 
lamina? If such a thing is, strictly speaking, possible, I do not be- 
lieve that it has been observed ; and all the known facts imply the 
necessity of both sides of the arch being involved. 

* Aurran, Journal de M6decine, 1771, tome xxxvi, p. 520. 



334 A TREATISE ON FRACTURES. 

A sack of flour, weighing three hundred livres, fell on the back of 
the neck of a stout porter at the market-hall. Severe pain was felt 
at the lower part of the neck; on examination, Boyer perceived that 
the spine of the seventh cervical vertebra was more prominent than 
naturally. Both the upper and the lower extremities were paralysed; 
respiration became labored ; the rectum and bladder ceased to act ; and 
the man died in five days. The autopsy revealed a fracture of the 
posterior lamina of the seventh vertebra of the neck, with depression 
of a fragment, which, bearing upon the spinal marrow, compressed 
it strongly. 

In order for the spine to have been thus prominent, it must have 
been detached' on each side; and in order for a fragment to have 
been depressed, the fracture must have been triple. The double 
character of the fracture is clearly indicated in the following case. 

A mason climbing a ladder with a hod on his shoulder, made a 
false step, fell backward, and struck the back of his neck against the 
angle of a stone. There was paralysis of the limbs, and insensibility 
of the skin; diaphragmatic respiration, aided only by the external 
muscles ; priapism, etc. ; death ensued two days afterwards. The 
autopsy showed fracture with depression of the laminae of the fifth 
cervical vertebra, and compression of the cord. 

These two cases show sufficiently the sort of displacement which 
may follow this fracture, and which is the cause of all the danger, 
from compression of the cord. But the fracture may exist also 
without displacement,, or at least with a displacement so trifling as 
not to compromise the cord. 

A man, in climbing over a carriage-wheel, fell backward, striking 
the back of his neck violently against the ground; his head was at 
the same time strongly flexed forward. On examination immediately 
afterwards, there was complete paraplegia, complete paralysis of the 
left arm ; the right arm was partially paralysed and painful, the fin- 
gers irregularly contracted; there was dyspnoea, and lastly slight 
twisting of the mouth to the right. There was a contusion on the 
occiput, and a deviation to the left of the spine of the seventh cer- 
vical vertebra, with mobility of this process as well as of the laminse 
attached to it. Inflammation was guarded against by bleeding, pur- 
gatives, and a blister to the nape of the neck. At the end of two 
months the paralysis began to diminish, and three years after there 
remained but slight traces of it.* 

The paralysis here evidently did not depend on compression, since 
it at length disappeared; it doubtless resulted from some concussion 
or contusion of the cord itself, a lesion entirely independent of the 
fracture, and often met with when the bone remains entire. 

* Ollivier, TraiU des mat de la moelle foinilre, third ed., tome i, pp. 270 
and 302. 



A TREATISE ON FRACTURES. 385 

The diagnosis is easy when we can grasp and move the spinous 
process and laminae as in the foregoing case; still we can never be 
certain that the fracture does not extend to the body of the bone. 

The prognosis would be extremely simple if the fracture were all; 
the danger results wholly from lesion of the cord. It is therefore 
very important to determine the nature of this lesion; it may easily 
be seen how the driving in of the posterior fragment should influence 
materially both the prognosis and the treatment. 

Fracture without displacement demands merely rest in bed, the 
other treatment being directed wholly against present or expected 
inflammation of the cord. If the fragment be driven in, there is one 
positive indication, viz., to replace it. 

Here, as in fractures of the spinous process, the ancients went be- 
yond the mark. " The vertebral arch (yertebrarum complexus)" says 
Paulus JEgineta, "is sometimes contused, rarely fractured. In these 
cases, the membranes of the cord or the cord itself participating in 
the contusion, the pain is propagated along the nerves, and death 
soon ensues; particularly if the lesion affects the cervical vertebrae. 
In consequence, having first given notice of the danger, we should 
act boldly, and if possible extract by excision the compressing frag- 
ment ; if this cannot be done, we must merely combat the inflam- 
mation." 

Such an operation would seem to me to be at once inopportune 
and dangerous ; inopportune, since we might resort to gentler means ; 
dangerous, in that if the dura mater is torn we risk the introduction 
of air into the cavity of the arachnoid. The only case suitable for 
it would be that of fracture with a wound and with splinters; the 
extraction of the latter would then be entirely rational. Louis per- 
formed it successfully in 1762, in a gunshot fracture in the dorsal 
region. The patient had instantly fallen, feeling himself paralysed 
in the lower limbs ; the wound was enlarged and the ball taken out. 
Louis saw him on the fourth day. Putting his finger to the bottom 
of the wound, he felt several loose pieces of bone, some of them of 
considerable size, and decided to remove them. The extraction was 
performed on the next day, with suitable precautions; the patient 
mended daily ; the paralysis diminished ; and twelve years afterwards 
he walked with a cane, his legs being still weak and emaciated, one 
much more so than the other.* 

But when we have to treat a double fracture, without any wound, 
it would be proper first to try if we could not seize the spinous pro- 
cess with the fingers, and draw it into place ; if not, we might seize 
hold of it with a pair of strong hooked forceps passed through the 
skin; and lastly, if necessary, we might resort to the curious plan 

* Louis, Remarque* <t obs. sur la fract. et la luxat. des vertlhres; M6m. 
posthume; Arch. G6n. de Mtdecine, August, 1836. 



336 A TREATISE ON FRACTURES. 

proposed by Fabricius Hildanus for luxations of the vertebrae; viz., 
to lay bare both sides of the spinous process and hook it with a pair 
of firm tenacula. It would not be difficult, in cases where the dis- 
placement tended to recur, to hold the spine back by means of a 
ligature attached to a dorsal splint sufficiently far removed from the 
integuments. 

Lastly, when the fracture has united with marked displacement, 
and paralysis seems to be kept up by the compression, does our art 
possess any resources ? Dr. Alban W. Smith, of Kentucky, has at- 
tempted to answer this question by the following case. 

A young man having fallen from a horse, had all his members 
paralysed, except the muscles above the elbow on each side. Dr. 
Smith found one of the dorsal spines deviated about three lines to 
the right ; he concluded that the vertebra was completely dislocated, 
and judging the case a fatal one, made no attempt at reduction. 
The patient however survived, and two years afterwards another sur- 
geon was consulted, who having made an exploratory incision down 
to the bone, considered that there was merely fracture of the base of 
the spinous process, compressing the cord. With this assurance, and 
being urged to it by the patient, Dr. Smith proceeded to operate; he 
made an incision of five or six inches along the dorsal spines, and at 
each end of this two others transversely, of three and a quarter 
inches each, down to the bone. The muscles were then detached 
from the vertebrae on each side, down to the transverse processes, 
and the bones properly rasped ; and thus the diagnosis was verified. 
The fragments were displaced laterally, but so completely fused, and 
offering so smooth a surface that the line of separation was not well 
marked. "With a Hey's saw, the operator divided first each side of 
the second dorsal vertebra, as near as possible to the bases of the 
transverse processes ; and in fact resected and raised up a portion of 
the spinous processes of two vertebrae, half that of the third, and all 
that of the fourth, which seemed most deeply driven in. No bad 
symptoms ensued; sensibility was regained in the thighs and in the 
hands, auguring well for the future re-establishment of motion. Un- 
happily the account terminates here.* 

This observation is open to more than one criticism. All the dates 
are omitted ; the seat of the lesion is not stated ; but, above all, the 
diagnosis was made out carelessly, the operation undertaken yet 
more rashly, and the final result remains unknown. It is not upon 
such cases as this that we can found any positive opinion. 

* North Amer. Med. and Surg. Journal, July, 1829, p. 94. This case has 
been reproduced in the Journal cles Progres and the Journal Hebdomadaire, 
but with a discreditable misinterpretation. 



A TREATISE ON FRACTURES. 837 



§ III. — Fractures of the Bodies of the Vertebras. 

The causes of these fractures are very various. Most commonly 
they are falls from heights, the posterior aspect of the trunk striking 
the ground; sometimes in the fall the trunk strikes against some- 
thing upon which the spine is broken ; thus masons or carpenters, 
falling from scaffolds, strike beams, bars of wood or iron, etc. Some- 
times again the person lights on one extremity of the trunk, — the 
pelvis or the head ; in the latter case the head is sometimes bent 
forward, when the force comes on the occiput, and sometimes it is 
thrown backward, when the force comes on the forehead. Several 
instances have been reported also of fractures following falls on 
the feet. Lastly come blows on the spine, which mainly result 
from falling bodies, or banks caving in; strong pressure, gunshot 
wounds, etc. 

Reveillon has related a case of fracture due, according to him, to 
muscular contraction. A soldier having dived from a height into 
some water not more than three feet deep, was taken out some 
minutes after, with paralysis of all his limbs. On coming to himself, 
he said that having touched the bottom with his hands, he threw his 
head suddenly back in order to save it, and from that instant was 
unconscious. He died in the night, and at the autopsy there was 
found a transverse frafture of the body of the fifth cervical vertebra, 
and separation of the laminae from the lateral masses.* 

However this may be, on examining closely the mechanism accord- 
ing to which these fractures take place, we come strongly to doubt 
the doctrine of Boyer, who admits only direct causes, and even that 
of some modern authors, who consider them more common than the 
indirect. It is certain first that, in falls on the head, on the pelvis, or 
on the feet, the fracture occurs by counter-stroke; and when a heavy 
body falls on the head or shoulders, causing forcible flexion forward, 
the counter-stroke is no less evident. There remain then falls on 
the back; now when no small projecting body is encountered, break- 
ing directly one or two vertebrae, — as for instance when the ground is 
level. — near]y always the chief shock is sustained by one of the most 
prominent points, the head, the upper part of the back, or the sacrum ; 
and in the second case, the only one in which the spinal column is 
directly involved, the shock is usually diffused over too large a sur- 
face to produce direct fractures. 

I assume, then, that in fact, in the great majority of cases, frac- 
tures of the bodies of the vertebrae occur by counter-stroke, as the 
effect of forcible flexion of the column either forward or backward; 
and the usual seat of these fractures demonstrates this. I have else- 

* Journal General de MMecine, tome xcviii, p. 418. 

22 



338 A TREATISE ON FRACTURES. 

where shown that the spine bends at three principal points, — com- 
prised, the first between the third and seventh cervical vertebrae, 
the second between the eleventh dorsal and second lumbar, the 
third between the fourth lumbar vertebra and the sacrum.* Now 
the majority of fractures involve the vertebrae situated between 
these points of flexion ; and luxations follow the same rule. Olli- 
vier 's work contains twelve cases of fracture of the bodies of the ver- 
tebrse ; three are of the sixth and seventh cervical ; five are between 
the tenth dorsal and first lumbar; the four others occupied the fourth, 
fifth, seventh and eighth dorsal vertebrae. The distribution is still 
more significant in the observations of Dupuytren. Excluding two 
cases of gunshot, there are thirteen cases in which the seat of frac- 
ture is clearly indicated ; in five cases it occupied the fourth, fifth 
and sixth cervical vertebrae; in all the rest it was about at the last 
three dorsal and the first lumbar. Finally, the Muse'e Dupuytren 
contains five specimens relative to these fractures ; one involves five 
of the cervical vertebrae at once; the four others are at different 
points between the tenth dorsal and the second lumbar. 

These fractures present quite numerous varieties, which would 
perhaps be explained by the variety of the causes, if the latter were 
always more precisely recognisable; the principal are transverse 
fracture, crushing, and oblique fracture. 

"We have already had an instance of transverse fracture in the 
soldier treated by Reveillon; here, whatever*opinion we may adopt 
as to its cause, the mechanism of the fracture still remains the same ; 
there was forcible flexion backward. Ollivier reports a case of 
transverse fracture of the seventh dorsal, and another of the first 
lumbar vertebra, one caused by a fall on the back, the other by a 
bank caving in; it is quite likely that both these causes acted like- 
wise by producing forcible flexion backward. 

Crushing or comminution seems on the contrary only attributable 
to forcible flexion forward. It presents itself in various degrees; 
sometimes the body of the bone, when comminuted, loses very little 
of its thickness ; sometimes it is reduced by one-half or more ; in the 
Muse'e Dupuytren are two striking examples of these two first forms. 
In a still higher degree, the body of the bone is almost entirely de- 
stroyed ; of this Ollivier has given a remarkable instance. A more 
singular variety is where the anterior portion of the body is crushed, 
and reduced to a few lines in thickness, while the posterior portion 
remains intact ; this was seen in a water-carrier who had been over- 
thrown by a heavily filled cask, the edge of which struck him violently 
at the lower part of the dorsal region. f 

Oblique fracture probably occurs from causes analogous to those 

* See my Anat. Chirurgicale, tome ii, p. 15. 
t Ollivier, op. cit., obs. 20 and 26. 



A TREATISE OX FRACTURES. 339 

of crushing; it is very remarkable that in all the known cases of it, 
its direction should be from above downward and from behind for- 
ward, so as to favor the overlapping of the fragments if the apophyses 
and ligaments situated posteriorly did not prevent it; of this there 
are two beautiful specimens in the Musee Dupuytren.* 

There are some other varieties, but they are in a manner irregular, 
and it would be idle to dwell upon them. 

Lastly, these different fractures may be isolated, the rest of the 
vertebra being intact, or they may be conjoined with fractures of the 
lamina? and of all the apophyses; perhaps it would be correct to 
say in a good many of these cases that the fractures of the arch are 
by direct violence, and those of the body by indirect. 

[I have recently had an opportunity of examining two specimens 
of fractures of the cervical vertebras ; in both cases the patients were 
men aged 19 or 20 years, and in each the cause had been a fall 
head-foremost through a hatchway. One lived ten days, and the 
other eleven, after the occurrence of the injury; both died with 
symptoms of slow suffocation. 

Case I. — Vertebrae involved, the 4th, 5th and 6th. 
4th. Vertical fracture affecting the posterior portion of the body; 
right lamina broken through, but undisplaced, a piece being chipped 
off; partial fracture of right lateral mass. 

bth. Complete vertical fracture of body and of right lamina, and 
lower anterior edge of body chipped off. (This vertebra had slipped 
forward so as to be dislocated from the 6th.) 

6th. Partial vertical fracture of the body, affecting its upper and 
anterior portion. 

Case II. — Vertebrae involved, the 5th, 6th and 7th. 
5th. Arch broken through close to root of spinous process. 
6th. Comminuted fracture of body, vertical posteriorly and trans- 
verse anteriorly; arch broken off at each side just behind the lateral 
mass, entire arch sunk down upon that of the 7th. 

1th. A small piece chipped off the upper anterior edge of the 
body, which also presented an extensive but incomplete transverse 
fracture in its upper portion.] 

The most constant phenomenon of these fractures is severe local 
pain, augmented by voluntary motion and by pressure with the 
fingers. Another, almost as constant, is paralysis of all the parts 
whose nerves take their origin below the fracture. This paralysis 
results sometimes from the tearing or compression of the cord by the 
displaced fragments; but more commonly it is due to a lesion of the 
cord independent of the fracture, as has been already said. Lastly, 
but exceptionally, the fragments are so distorted as to furnish both 
to the eye and to the touch plain indications for the diagnosis. 

* See the Atlas of the Muste Dupuytren, pi. i and ii. 



340 A TREATISE ON FRACTURES. 

The displacements arc of three kinds. Sometimes one of the 
fragments passes forward, the other remaining in place; this is seen 
in some transverse fractures, and it is always the upper fragment 
which slips forward. If the fracture is oblique, the upper fragment 
slides forward and downward, sometimes to such an extent as to be 
entirely in front of the other. When there is crushing of the bone, 
the displacement is almost entirely by penetration, the upper part of 
the column being at an angle with the inferior; this angle is always 
and essentially open anteriorly, rarely with some inclination to one 
side or the other. If any sliding occurs of the two portions one on 
the other, it is still the superior which passes forward, so that in all 
these fractures, if there is displacement, the general law is that it 
should be the upper fragment which is anterior. 

The necessary consequence of these displacements is deformity of 
the vertebral column, which should be easily perceived posteriorly in 
the median line, where the spinous processes are. covered only by the 
skin. When the upper fragment is carried forward, the spinous 
processes above the fracture should be less, and those below it more, 
prominent ; and at most we should doubt whether it were a fracture 
or a luxation. When there is overlapping or crushing, the angle in 
front, an entering one, is represented posteriorly by a salient one; 
sometimes this prominence is due only to the spine of the vertebra 
involved. In the water-carrier who had only the anterior portion of 
the* body of the bone crushed, the prominence was rounded, formed 
by three spinous processes separated from each other by two fingers'- 
breadths. 

Who would not suppose that in these cases, at least, the diagnosis 
would be easy? And yet in a young girl who had had the body of 
the fifth dorsal vertebra completely crushed, MM. Dumeril, Roux 
and A. Dubois did not recognise the fracture.* Swelling, pain, and 
sometimes embonpoint, are obstacles to an examination regarded at 
any rate as but of moderate utility. Moreover, fractures of the pos- 
terior arch and its apophyses, in place of affording any light, often 
serve only to mask the most fearful displacements. Of this a curious 
instance is given by W. Lyon. In a patient, the autopsy upon whom 
showed complete overlapping of the upper vertebra in front of the 
lower, there had been during life only a slight prominence pos- 
teriorly. This was because the spine of the upper vertebra, fractured 
at its base, became horizontal instead of maintaining the obliquity 
proper to the apophyses of the dorsal region, thus filling up in great 
part the space which the displacement would otherwise have left at 
this point, f It will readily be seen that the difficulty increases as 
the displacement becomes less ; and when fracture occurs without 
displacement, the diagnosis is absolutely impossible. 

* Ollivier, op. cit., obs. 20. f Gazette Mtdicale, 1845, p. 43. 



A TREATISE ON FRACTURES. 341 

The prognosis is very doubtful, and most commonly very grave, 
much more from the lesion of the cord than from the mere fracture, 
although the crushing and overlapping of the fragments may, if at 
all marked, leave the patient irremediably deformed. Sir A. Cooper 
shows that in the lumbar region fractures with displacement prove 
fatal generally in about four or six weeks ; in the dorsal region, in 
two or three weeks ; in the three lower cervical vertebrae, from the 
third to the seventh day; above the third vertebra, almost imme- 
diately, by causing paralysis of the phrenic nerve. In connection 
with luxations I shall recur to the entire history of the symptoms 
induced by lesions of the spinal cord. But Sir A. Cooper's rule for 
the prognosis would involve too serious consequences as to our treat- 
ment, unless reduced to its true value. 

In the first place, he alludes only to those great displacements in 
which the upper fragment slips from the lower by half an inch or an 
inch; and he himself cites notable exceptions to his own rule. Thus 
he saw a. patient with fracture about the loins survive the accident 
for two years ; others, with fractures in the dorsal and lower cervical 
region, for nine or ten months; and I could myself give other in- 
stances. Doubtless the displacement in them was not an inch, or 
even half an inch; but as it is impossible to measure its extent dur- 
ing life, we should evidently not give up all hope too soon. I have 
seen at Bicetre a patient completely paralysed in both lower limbs in 
consequence of the caving in of a bank, fracturing, as well as could be 
judged, one of the lumbar vertebrae ; the accident had occurred more 
than six years before. 

[Two cases diagnosed as fractures, one at the lower part of the 
dorsal and the other at the middle of the lumbar region, are re- 
ported for the Am. Journal of the Med. Sciences for October, 1857, 
by Dr. Lente, of Cold Spring, N. Y. In both, very satisfactory 
results were obtained.] 

The treatment, with most surgeons, amounts to very little; the 
patient is to be laid on his back, on a mattress supported by a board, 
his head somewhat raised; he is to be so fixed by means of folded 
cloths, etc., as to favor consolidation ; inflammation of the cord is to 
be combated; the consequences of paralysis to be guarded against; 
such are the indications generally admitted; and when no, sign of 
displacement exists, such is in fact the line of practice to be followed. 

But when we have reason to suspect displacement, should we 
remain passive spectators, or should we attempt reduction? I have 
given my views on this point as to simple fractures of the posterior 
arch, and a series of plans to be tried even if the body of the verte- 
bra should be involved. But in the body of the bone itself, what 
reasons are there against reduction? Sir A. Cooper believes it im- 
possible to be performed or to be maintained; others add that there 
is danger of increasing the compression of the cord, or of forcing 



342 A TREATISE ON FRACTURES. 

splinters into its substance. The objection to reduction, as being 
impossible, is nullified by facts, as will be seen in connection with 
luxations; the objection that it is dangerous is still more trivial; the 
danger lies in our inaction, and is too great for us to dread increas- 
es [t - 

In 1843, at the Hopital des Cliniques, I had to treat a case of 

fracture in the lumbar region, with prominence of the spinous pro- 
cess, and paraplegia; I placed under the upper portion of the mat- 
tress an inclined plane of forty-five degrees, and the trunk was fixed 
thus at this angle by means of a cloth folded cravatwise, passed under 
both armpits, and fastened at the head of the bed. At the same 
time cushions were made to support the loins, so that I used at once 
extension and pressure, to lessen the sinking in which I presumed 
had occurred in the body of the bone. The paralysis passed off 
before long, and the patient recovered without difficulty. 

This was the only case in which I have thought fit to resort to 
extension; and this position being very fatiguing, I should now pre- 
fer laying the patient on his back, making extension at first with a 
loop under the armpits, and another round the pelvis; rendering 
this permanent, if necessary, by fixing the loops to the head and 
foot of the bed, and placing cushions beneath the seat of fracture. 
Mr. "W. Tuson, in England, obtained from temporary extension such 
remarkable results, that even allowing for some little exaggeration, 
they should fix the attention of surgeons. A man fell from the top 
of a carriage, striking on his back ; he heard at the moment of his 
fall a crack behind his neck; his legs were entirely paralysed; there 
was priapism ; and on examination of the spinous processes of the 
seventh cervical and first dorsal vertebrae, where the force had been 
sustained, a slight displacement was perceived. Tuson had his head 
held firmly, drawing at the same time strongly and steadily on his 
legs; the man immediately said he was well, and raised up and 
moved his legs; the priapism ceased. However, the cure was not 
completed, nor the powers entirely restored, until after about five 
months. 

In contrast to this simple and regular plan, for which experience 
will present us with new arguments in connection with luxations, 
another doctrine has been put forth, the first traces of which date 
back to the times of Paulus iEgineta, but which, until our time at 
least, has remained purely theoretical ; I allude to the use of the 
trepan. Chopart and Desault are the first to speak of it, as a very 
simple thing, to trepan between the spinous and transverse processes, 
to give issue to effused fluids, to elevate or remove pieces of bone 
which may wound the cord; but Boyer, wiser this time than in re- 
gard to fractures of the cranium, objects strongly that we have no 
sign by which to distinguish between compression by a piece of bone 
or by an effusion, and any other lesion of the spinal marrow. Still, 



A TREATISE ON FRACTURES. 343 

Sir A. Cooper did not hesitate subsequently to give his imposing 
approbation to this proceeding. "Mr. Henry Cline," says he, "is 
the only man who has looked on this indication in a scientific light. 
He considered the case as entirely similar to fracture of the cranium 
with depression, and as offering the same demand for relieving the 
compression ; and as such cases always terminated fatally, he thought 
himself justified in deviating from the usual path in the hope of 
saving life. The patient lying on his face, an incision was made 
over the depressed bone, and the muscles covering the vertebral arch 
were raised up ; a small trepan was then applied to this arch, divid- 
ing it on each side, so that the spinous process and the arch pressing 
on the cord could be elevated." The patient died. Sir A. Cooper 
even adds that he is not sure that the operation ever could succeed; 
still in desperate cases he would consider it laudable. 

In 1822, an occasion was again afforded for trying it; and en- 
couraged by Sir A. Cooper, Tyrrell removed, either with the trepan 
or with suitable saws, the spines and laminse of the ninth and tenth 
dorsal vertebrae; the patient died on the fifteenth day. The same 
operator made another attempt in 1827; with a chain-saw and a 
Hey's saw he removed the spine and arch of the twelfth dorsal ver- 
tebra; the performance occupied more than three-quarters of an 
hour; death ensued five days afterwards. Dr. J. Rhea Barton is 
said to have done the same, with the same result. Lastly, in 1840, 
M. Laugier applied a crown of the trephine at the base of the spinous 
process of the ninth dorsal vertebra, so as to enlarge the canal 
without removing the apophysis; the subject died on the fourth day.* 

[An account of Dr. Barton's operation may be found in Dr. John 
D. Grodman's edition of Sir A. Cooper's " Treatise on Dislocations 
and Fractures of the Joints," p. 421. It is as follows : — 

Dr. Barton's "views relative to this operation are very ingenious 
and deserving of consideration. His object in cutting down to the 
vertebrae is not the mere elevation or removal of a depressed or frac- 
tured portion of the bone, but the excision of a^ many of the spinous 
processes as are external to the angle formed by the dislocation of 
the vertebrae. This he thinks will allow the spinal marrow to curve 
outward so as to free it from pressure, and also allow matter or ef- 
fused blood to be readily discharged. 

"J. P. was received into the Pennsylvania Hospital, August 18, 
1824, with a fracture of the spine, caused by a fall from the mast- 
head of a brig. The lower part of the trunk, and the inferior ex- 
tremities, were totally paralysed. He continued in this state, dis- 
charging his feces and urine involuntarily, until the 30th of August, 
when Dr. Barton performed the following operation. An incision 

* See for these different cases, Ollivier, op. cit., tome i, p. 381 ; The Lancet, 
vol. xi, p. 685 ; Laugier, Bulletin Chirurg., tome i, p. 401. 



344 A TREATISE ON FRACTURES. 

was made about eight inches in length immediately over the injured 
fertebne. He found the spinous process and arched portion of the 
seventh dorsal vertebra broken off and depressed on the spinal mar- 
row. When this was done it was ascertained that the bodies of the 
seventh and eighth dorsal vertebrae were dislocated from each other, 
without any fracture but that above mentioned. Lint was laid over 
the wound. The paralysis not being immediately relieved, it was 
inferred that compression was kept up by blood effused within the 
spinal canal, which would possibly escape with the suppuration from 
the wound. 

"About forty-eight hours from the time of operation, sensibility 
began to return below the injured vertebrae, and gradually extended 
toward the toes until the third day, when he was attacked with a 
violent chill, which continued, notwithstanding all the stimulating 
medicines given, until his death, which occurred in twelve hours from 
its commencement. 

"An examination was made next day, to ascertain the real state 
of the spinal column. On opening the thorax, the posterior medias- 
tinum was found filled by about half a gallon of coagulated blood, 
which accounts for the difficulty of respiration, especially when he 
lay on his back. This being cleared away, the condition of the ver- 
tebral column was seen. The seventh and eighth dorsal were injured 
as before stated, the body of the ninth was fractured, and blood was 
effused throughout the spinal canal." 

A writer in the Brit, and For. Med. Review for 1838 (page 162,) 
reviewing Sir C. Bell's "Institutes of Surgery," says: — "We are 
free to admit that the cases in which an attempt has been made to 
elevate a depressed portion of the spine have not been very success- 
ful. We know of only four cases ; and of these, one was performed 
successfully, as we are informed, only a few months ago, by a sur- 
geon of the name 4 of Edwards, living at Caerphilly, in South AVales. 
There were present the usual symptoms of compression, — paralysis 
of the organs of locomotion, the rectum, and the bladder ; the situ- 
ation, as far as the operation was concerned, was unfavorable, — the 
lumbar region ; the posterior arch of the bone was raised, the symp- 
toms of compression relieved, and the patient did well." 

Dr. Xorris informs me that this latter case is the only one with a 
successful result out of ten of which he has collected notes. One 
operation, done by Potter of New York, three months after the 
receipt of the injury, was followed by a return of sensibility for a 
short time ; but the patient died on the eighteenth day.] 

These results should be sufficient to deter surgeons from so grave 
an operation. I would add, in answer to Sir A. Cooper, that it is 
not accurate to call it our only scientific resource. In every frac- 
ture with displacement, the most scientific and rational plan is first to 
attempt reduction by the ordinary methods; and to this rule fractures 



A TREATISE ON FRACTURES. 345 

of the vertebra do not constitute an exception. If the ordinary- 
methods are not sufficient, we may try to act on the posterior frag- 
ment with forceps or tenacula, to draw it backward ; and the extrac- 
tion or trephining of the arch presents itself as so desperate a re- 
source that I would not advise any one to adopt it. I say desperate, 
I should say also blind, for at least hitherto it has always been 
undertaken at great risk, and has never been justified by the results. 
Take the completest case, that of M. Laugier; on examining the 
dorsal region of the patient, there was no deformity found along the 
spinal column. Whence then the indication for operating, and* what 
the object in view? I cannot divine. The risk at any rate, that 
melancholy and feeble argument, — could it afford to the operation an 
unhoped-for justification? Not at all; neither in the details of the 
operation, nor in those of the autopsy, do we find anything indicating 
any pressure from the part of the arch which was trephined; and 
had such pressure actually existed, a last counter-indication was 
revealed by the scalpel, — the cord was entirely broken across. 



CHAPTER' VI. 

OF FRACTURES OF THE RIBS. 

Fractures of the ribs are among the most common of all frac- 
tures ; they amount to 263, or just one-ninth, of the 2358 cases at 
the Hotel-Dieu. The influence of the seasons in their production 
seems to be nothing; but it is quite otherwise with age and sex. Of 
the 263 cases at the H6tel-Dieu, forty-eight only, about one-fifth, 
occurred in females. The following table will show the influence of 
age :— 

At 9 years 1 (compound.) 

From 15 to 20 years 2 



20 to 30 
30 to 40 
40 to 50 
50 to 60 
60 to 70 



11 

48 
72 
68 
49 



Above 70 years 12 

Whence we see how rare these fractures are in youth, and how com- 
mon in old age. For my own part, I have never seen one under 
fifteen years of age ; while in the two years which I spent at Bicetre, 
the fractures of the ribs alone were nearly as numerous as those of 
all the other bones put together. In infancy, the elasticity of the 
ribs permits of their resisting the most violent pressure. Thus 
A. Pare* has related the case of a child two years old, over whose 
chest a carriage with five persons in it passed twice, without any 
indication of fracture of the ribs.* In adult age, this elasticity 
is lost, still more from the ossification of the cartilages; but besides, 
the ribs are subject to a kind of senile atr6phy, affecting them chiefly 
in their thickness, and making them much more fragile. This atro- 
phy, which I have nowhere seen mentioned, is observed also in some 
affections of the interior as well as of the exterior of the chest; I 
have ascertained its presence in a case of pulmonary emphysema ; I 
have seen the same in a woman affected with cancer of the breast, 
not adherent to the ribs or even to the great pectoral muscle, — I 

* A. Pare, edition by Maleraigne, tome iii. p. 489. 
(346) 



A TREATISE ON FRACTURES. 347 

have seen, I say, all the subjacent ribs so much thinned as to pre- 
sent a thickness three or four times less than that of those of the 
opposite side. 

The usual causes are external violence, a severe blow, an excessive 
pressure, or a fall on some projecting body, as the edge of a step, 
the angle of a table, or even a fall from a height to the ground. 
Lonsdale has seen nine or ten ribs on each side broken by the last- 
mentioned cause. 

How do these various causes act? J. L. Petit has given a theory 
as to this, which still prevails in our schools ; the rib according to 
him represents an arch, which may have its middle portion driven in, 
fracture inward, called also direct; or perhaps a pressure exercised 
on both ends, tending to approximate them, forces the middle por- 
tion outward, fracture outward, or indirect. 

This theory is correct only within certain limits. Thus a blow or 
strong pressure, acting on the middle of the rib, causes frequently 
only a direct fracture ; but it sometimes also occasions indirect 
fractures at other points ; and it is thus that multiple fractures 
occur. We need not however suppose from the expression frac- 
ture inward, that the rupture always commences with the inner 
table of the rib ; sometimes it is confined entirely to the outer one. 
A man seventy-seven years old fell against the arm of a sofa, and 
broke five ribs, from the third to the seventh, on the right side ; he 
died on the third day. At the autopsy I found in four of the ribs 
complete fractures ; but the fifth, the one in the middle, had the ex- 
ternal table only broken ; the inner one had bent, and formed an 
angle salient inwardly. Fig. 10 shows this specimen as seen from 
within, and the angle formed by the partially broken rib in the 
middle. 

As to indirect fractures, produced by pressure on both ends of a 
rib, they do not, as was believed by J. L. Petit, occupy the middle 
portion of the bone. I have frequently tried breaking the ribs by 
powerful pressure on the sternum, and the fractures have always 
occurred anteriorly, generally even nearer to the sternum than to 
the middle of the rib.* In several cases of indirect fractures caused 
in the living body by wheels passing over the sternum, I have ob- 
served the same fact ; and at the time of the sad occurrence in the 
Champ de Mars, in 1837, seven persons having died from fractures 
of the ribs arising probably from indirect violence, all the fractures 
were found in front, from two to seven millimetres or more from the 
cartilages. 

It is otherwise when the pressure is applied posteriorly, the sub- 
ject lying on his face. In a case reported by Zwinger, the man 

* Malgaigne, Recherche* sur les var. et le trait, des fract. des cotes ; Archiv. 
Ge'n. de He'd,, July and August, 1838. I would refer the reader to this memoir 
for the sources of any quotations which may have been omitted in this chapter. 



348 A TREATISE ON FRACTURES. 

being thrown down on his face, a horse and a heavy carriage passed 
over his back. Singularly enough, the fractures in the lower ribs 
were seated anteriorly, even in the very cartilages, while the three 
upper ones were broken and depressed close to the spinal column. 

Fractures from internal causes have been overlooked by most 
surgeons. I have collected seven such instances, related by Gooch, 
Monteggia, Graves of Dublin, C. Broussais, and Nankivell; another 
has been observed at the Hopital Necker.* Of these eight cases, 
four occurred in men and four in women. The age is given in six ; 
five were in persons between forty-seven and sixty-three years of 
age ; the sixth was in a young man. In seven cases the cause was 
manifestly a severe effort at coughing ; in that of M. C. Broussais, 
the patient having been unable to give any particulars, but having 
at the same time chronic pneumonia and eccentric hypertrophy of 
the heart, it might be questioned whether the beating of the heart 
had not some share in the production of the fracture, which occupied 
the fourth true rib, at the junction of its anterior fourth with the 
rest of the bone. It is very remarkable that in all the cases in which 
the seat of the fracture has been indicated, this was somewhere in 
the anterior half, and generally near the cartilages; what is not less 
remarkable is that so far no instance has been known of such a frac- 
ture occurring on the right side. In the cases hitherto known, the 
ribs involved have been the fourth, fifth, and sixth, then the ninth, 
tenth, and eleventh, the seventh and eighth being exempt. Gene- 
rally but one rib is affected ; once only the fracture occurred simul- 
taneously in the fifth and sixth; and in the likewise curious case at 
the Hopital Necker, there took place in less than one month three 
successive fractures, affecting first the tenth, then the ninth, and 
lastly the eleventh rib. On the whole the tenth seems to be the rib 
most exposed. 

I think it very probable that in all these cases the ribs had under- 
gone more or less of the atrophic thinning of which I have before 
spoken ; and that the fracture was induced by muscular action, which 
in coughing approximates the sternum and the spinal column, just as 
exterior pressure does. 

Fractures of the ribs present numerous varieties of seat and ar- 
rangement. The middle ribs are naturally more exposed; the first, 
being protected by the clavicle, and the last, which is small and floats 
freely among the tissues, are very rarely involved, and perhaps never 
alone. In one case related by Derrecagaix, the last rib was broken 
along with the seven immediately above it ; in another, by M. J. Clo- 
quet, the four last ribs on the left side were all broken at once, each 
at two different points, f Again, M. Lisfranc saw the upper six ribs 

* Gazette des Hopitaux, February 6, 1841. 

f Journal de Desault, tome iii, p. 9 ; Diet, de Mid. en 30 vol., art. Cotes. 



A TREATISE ON FRACTURES. 349 

fractured at once, and Chaussier the first nine; it is remarkable that 
in neither of these cases did the clavicle suffer. 

In general, these multiple fractures affect but one side of the 
chest; sometimes both sides are involved; I have already quoted 
Lonsdale's case, and Ollivier d'Angers, in one of the persons killed 
at the Champ de Mars, counted as many as thirteen ribs broken. 
In reference to each rib in particular, fracture may affect any por- 
tion of its extent; but the anterior part is more exposed than any 
other. 

As to their arrangement, fractures of the ribs may be complete or 
incomplete, single or multiple. 

Incomplete fractures are sometimes mere fissures, following the 
length of the rib, or perhaps a fissure, involving one edge, and then 
running along the rib without reaching the other. M. Lisfranc satis- 
fied himself as to the occurrence of these two forms in an autopsy on 
a young girl overset by a cabriolet. It is much more common to find 
the fracture limited to one table of the bone ; Cheselden, Michault, 
and Chaussier, have reported instances of fracture of the inner table ; 
and I have already mentioned Fig. 10 as a good example of one of 
the outer. 

Among complete single fractures, some are transverse or oblique, 
presenting a clean crack, so that the fragments are held in contact 
only by the periosteum or by the muscles, and may be moved upon 
one another so as to cause crepitation. But more frequently, per- 
haps, the fracture may be serrated ; and then, although we can rub 
the fragments together, we cannot generally so disengage them as to 
produce crepitus. 

Multiple fractures are far more diversified. Sometimes, as in 
Chaussier's case already quoted, there are two partial fractures ; 
sometimes a complete fracture is conjoined with an incomplete one, 
or perhaps both are complete ; and lastly, I have examined anatomi- 
cal specimens presenting incontestable traces of three or four frac- 
tures in a single rib. I say nothing of comminuted or splintered 
fractures ; they often occur when a rib is broken \>j gunshot ; but to 
my great amazement, I have not found a single such case produced 
by ordinary causes, and on the dead subject I have not been able to 
obtain them. 

The symptoms of these fractures vary as much as their form. 

Some patients say that at the time of the blow they heard the 
crack of the bone; but that is nothing less than common. It is quite 
as rare to find any contusion or ecchymosis externally. 

The most constant phenomenon is local pain, increased by the 
movements of respiration, especially by strong inspiration, by exer- 
tion, and by coughing; by external pressure; sometimes, more or 
less, according to the seat of fracture, by movement of the shoulders. 



350 A TREATISE ON FRACTURES. 

It begins from the instant of the injury, and is only allayed by rest 
or immobility of the thorax, and by the reduction of the fragments. 

In the simplest fractures, when care has not been taken to render 
the chest motionless, the pain usually persists ; sometimes the slight 
irritation which occurs around the fragments is propagated to the 
pleura; if the ear or the stethoscope be applied, we shall hear a fric- 
tion sound denoting slight circumscribed pleurisy ; and I have seen a 
fracture of a rib, placed by mistake in a medical ward, give rise in 
this way to an odd error in diagnosis. On the other hand, a bandage 
being applied, the pain promptly subsides ; many patients in hospi- 
tals request to be discharged about the eighth to the tenth or twelfth 
day, a period when osseous consolidation certainly cannot yet have 
occurred. 

When the fracture is multiple, and one fragment is driven in, the 
pain is deeper and more fixed, and seems due to contusion and par- 
tial inflammation of the lung and of the pleura; the bandage, so far 
from alleviating, often exasperates it; I have sometimes then seen 
the thorax, either by reason of the pain, or from the irritation and 
tension of the muscles, become of itself immovable on the affected 
side, the costal respiration being carried on exclusively by the sound 
side. 

The decubitus, in these cases, has not seemed to me to follow any 
general rule ; I have seen some patients who could only lie on the 
sound side ; others, on the contrary, who could only lie on that af- 
fected; and others, again, in whom it was a matter of indifference; 
and I have as yet been unable to detect the cause of these anomalies. 

It might be presumed, from the incessant movement of the ribs, 
that crepitation would commonly exist, and even be heard without 
any effort to induce it. I have seen a remarkable case of this in a 
man aged 32, with a simple fracture of the ninth rib on the right 
side, which from the fourth to the fourteenth day produced a crepitus 
perceptible by himself as well as by others, in certain movements, 
and in somewhat deep inspirations. Chaumette observed something 
much more remarkable in his father-in-law, Claude Chillac, who sus- 
tained a penetrating wound of the thorax, opposite the heart. "II 
auoit aussi vne coste rompue," says he, u et entendions aisSment son 
remuement lorsque le coeur se mouuoit." But all this is excessively 
rare ; very often, on the contrary, whether from incompleteness or 
impaction of the fracture, or from swelling of the surrounding parts 
keeping the two fragments in contact, all attempts at producing cre- 
pitation are unsuccessful. 

The displacements remain to be studied. J. L. Petit, as has been 
seen, alleged that the two fragments might be driven either outward 
or inward by the violence, while admitting that the intercostal mus- 
cles would prevent them from being greatly deranged; and Vacca 
Berlinghieri, over-estimating the resistance of these muscles, went so 



A TREATISE ON FRACTURES. 351 

far as to deny the possibility of displacements. All this is pure 
theory, and cannot stand before the facts. 

In fissures, in the great majority of incomplete fractures, and in 
complete fractures when serrated and unattended by rupture of the 
periosteum, there is no displacement of any kind. In some simple 
incomplete fractures, situated near the sternum, there may be angu- 
lar bending of the rib inward, with a corresponding depression out- 
wardly; this I have seen in several specimens ; I have been able to 
cause it in the dead subject, and Fig. 10 affords an instance of it. 

Complete fracture, when the fragments are held in place neither 
by their serrations nor by the periosteum, is almost always attended 
with real displacement; thus the anterior fragment projects some- 
times backward, sometimes forward — sometimes upward, and some- 
times downward ; all these forms I have observed in specimens. 
These projections are usually very slight, mostly limited to one or two 
millimetres, except toward the anterior end of the rib, where, by a 
mechanism which can be better explained in connection with frac- 
tures of the cartilages, they may reach four millimetres or more. 
M. Voisin has published an account of an autopsy in which he found 
a fracture of the second rib three inches from its cartilage, with an 
overlapping of nearly half an inch.* But overlapping is more com- 
mon in fractures involving several ribs, as will be presently shown. 

When, along with an incomplete fracture, there exists at some dis- 
tance from it a complete one, the middle fragment is generally nota- 
bly driven in ; it makes an angle salient outwardly with the fragment 
to which it still holds, but it leaves the other more or less entirely; 
of this I have seen four instances. In all these cases, the fractures 
had occurred from the passage of a carriage-wheel ; and the pain was 
intolerable. We have reason then to fear lest the fragment driven 
in may have penetrated the lung; hence sometimes emphysema, effu- 
sion of blood into the pleural cavity, or traumatic pneumonia. 

Lastly, when the rib is completely fractured at two, three, or four 
points, sometimes there is little or no displacement, sometimes it is 
very great. Sabatier saw a case of this kind, in which the mere 
play of the lung had given rise to a very curious displacement. The 
last two true ribs had been fractured by the passage of a carriage- 
wheel ; but the lower one was broken in two places, and in such a 
way that the middle fragment, being quite movable, was drawn into 
the chest in inspiration, and pushed outward in expiration. [Proba- 
bly the author meant just the reverse of this ; the fragment would 
be pushed outward in inspiration, dratvn in in expiration.'] Saba- 
tier adds that the patient recovered perfectly. f This is certainly 
quite an exceptional case ; generally, judging from the anatomical 

* Gazette MCdicale, 1832, p. 465. 

f Mtmoires de V Institut, tome vii, an vii, [1799,] p. 119. 



352 A TREATISE ON FRACTURES. 

specimens that I have seen, one of the ends of the middle fragment 
lias projected outwardly, while the other was driven inward. 

Hitherto I have alluded only to displacements in fractures of sin- 
gle ribs; they are much more marked when several are broken at 
once ; and they differ again according as the fragments are few or 
many. 

Fig. 9 presents a fine example of simple fractures of eight ribs, 
from the second to the ninth inclusive. As, owing to these simulta- 
neous fractures, the ribs could no longer support one another, there 
has resulted in several of them an actual overlapping to the extent 
of more than a centimetre. In the upper four, the sternal fragment 
has passed above the other; in the rest it has remained at the same 
level, or even been a little driven in. It may be seen also to have 
generally descended a little below the vertebral fragment. But what 
is much more remarkable is the narrowing of most of the intercostal 
spaces, carried so far as to result in fusion of the sixth, seventh, and 
eighth ribs. The first cause of this is doubtless the overlapping, 
which, by shortening the ribs, necessarily diminishes the diameter 
and the circumference of the chest ; but I think we should add to 
this the muscular irritation excited by so great an injury, which 
would have the effect of forcing the ribs still more closely together. 
The specimen was presented to the Musee Dupuytren by M. Poumet. 

When multiple fractures exist in several ribs at once, as from the 
passage of a wheel over the chest, the displacement is different again ; 
and often even in the living subject the very first glance puts us in 
the way of making up our diagnosis. We perceive a hollow, more 
or less wide and deep, marking on the surface the course of the 
wheel ; and if on exploring it with our fingers we feel no projection 
of one of the fragments, if increased pressure augments momentarily 
the depression without causing any projection, we may affirm the ex- 
istence of multiple incomplete fractures. I have published quite a 
remarkable case of this, where the fourth and fifth ribs on the left 
side presented such a depression without any prominence, while in 
the sixth and seventh complete fracture was indicated by very marked 
projections. 

From all that precedes, it may be concluded that the diagnosis is 
very often obscure and equivocal. When, as the result of external 
violence, there is fixed pain, localised somewhere in the course of a 
rib, with the characters pointed out above, but without any other 
sign, we may suspect, but not affirm, the existence of fracture ; for 
it may be that there is only a contusion. This would be a probable 
diagnosis merely. 

If any displacement can be clearly made out, the diagnosis be- 
comes certain. But here also there are sources of error. When the 
displacement forms a wide hollow, we must ascertain that there has 
been no former lesion, as rachitic distortion or old fracture. The 



A TREATISE ON FRACTURES. 353 

insertions of the external oblique and serratus magnus might induce 
us to suspect depression of one fragment and projection of the other, 
by reason of their sudden swell under the fingers, especially when 
they are contracted with the pain. Many subjects present also re- 
markable prominences at the junction of the ribs and their cartilages, 
owing to abrupt enlargement of the ends of the bones. 

Crepitation forms, here as elsewhere, the true pathognomonic sign; 
it cannot be simulated except by emphysema, which is of very rare 
occurrence, and easily diagnosed. But to obtain crepitus is often 
very difficult. It has been advised for this purpose to press alter- 
nately on the fragments ; a plan specious in theory, but nearly al- 
ways useless in practice. The means which has seemed to me most 
efficient consists in applying over the part the palmar face of four 
fingers, and then making the patient cough ; but the surgeon should 
bear in mind still that this may not at first succeed ; and that even 
after having once perceived crepitus clearly, the process may be seve- 
ral times repeated in vain. 

The prognosis is very simple in uncomplicated fractures. Consoli- 
dation rarely fails to occur, even in animals, when no apparatus is 
applied ; and it only takes twenty-five or thirty days. I have seen 
but a single instance of non-consolidation in a fractured rib ; M. Hu- 
guier told me that he had not met with one in the dead body. The 
articulation in my case was remarkable in having a capsule and a 
synovial membrane ; which shows that the two fragments must have 
executed from the first quite extended movements upon one another. 

In fractures with irreducible depression or overlapping, it is to 
be feared that the patient will have at the point of injury a dull pain, 
very slow to disappear ; but this is not constantly the case. When, 
lastly, we have to deal with either single or multiple fractures in- 
volving several ribs at once, the prognosis becomes much graver; 
not on account of the fractures themselves, but because of the 
accompanying symptoms. Sometimes a fragment, driven in, pene- 
trates one of the cavities of the heart ; Lonsdale and Dupuytren saw 
instances of this.* Death is then almost immediate. Amesbury 
relates a case in which, three ribs being broken, death ensued by 
hemorrhage from the intercostal artery, without any lesion of the 
lungs. But much more frequently the lungs are contused, broken, 
or torn ; the patient may then survive some hours or even days. If 
the pulmonary lesion is less severe, there may ensue only an exter- 
nal emphysema, hardly demanding any attention ; or the pleura and 
lung may become inflamed, and increase again the chances of death. 
This may suffice to explain the exceptional mortality of these frac- 
tures. Of the 263 cases at the Hotel-Dieu, there were twenty deaths, 
twelve of which occurred from the first to the fourth day, five from the 

* Gazette des Hopitaux, June 1, 1830. 
23 



354 A TREATISE ON FRACTURES. 

seventh to the eleventh, and three from the seventeenth to the twenty- 
fifth. 

The treatment commonly followed in fracture of the ribs is based 
on the theories of J. L. Petit or of Vacca. According to the latter, 
as there is no displacement, the only indication is to render the ribs 
immovable ; according to the former, when the iracture is outward 
we should exert upon it a permanent pressure to push the fragments 
inward ; and when it is inward, we should press at once on both ex- 
tremities, so as to push the fragments outward. The reader will 
know how to value these theories ; we therefore lay them aside, and 
examine the indications. 

If the fracture is without displacement, there is manifestly no re- 
duction to be made. If there is very slight displacement, or even 
when, owing to several partial fractures, there is perceptible depres- 
sion, but no pain except that arising from movement or from respira- 
tory efforts, reduction is of trifling importance, and calls for the use 
of too much force. In all these cases, then, the only indication is to 
fix the chest, so as to dissipate the pain and insure consolidation. 
The numerous means recommended to this end, the paddings, the 
plasters, the leathern girdle of Yerduc, the complicated apparatus 
of Lavauguyon, and the still more complicated one of Baillif, act only 
by circular constriction. In France we have generally adopted the 
body-bandage, or a towel folded twice or thrice, surrounding the 
chest and fastened with three or four pins. If this tends to slip 
down toward the abdomen, it may be kept up by means of bands 
passing over the shoulders like suspenders. 

This apparatus is certainly very simple, but it is not always with- 
out its inconveniences. In the first place, it is apt to become loose ; 
Dupuytren therefore added a roller, applied over it, and Boyer sub- 
stituted for it the quadriga, consisting of a figure-of-8 bandage 
around the shoulders, and spiral turns around the trunk ; an appa- 
ratus as apt to become relaxed as the body-bandage itself. Again, 
from its breadth, it is applied with difficulty to women who have 
large breasts ; it must, therefore, in such cases be doubled, and ap- 
plied below the breasts; but then there is danger of its slipping 
down. Now one of the essential conditions to be met is, that while 
the thoracic respiration is impeded the diaphragmatic should be left 
free, and hence the abdomen must not be compressed. 

For all these reasons, I greatly prefer a strip of adhesive plaster, 
three or four fingers'-breadths wide, long enough to go once and 
a half around the body, and applied either directly to the skin or 
over a turn of a roller. A broad band fastened by a buckle would 
answer the purpose just as well. 

[In the Pennsylvania Hospital, and probably in most parts of this 
country, the local treatment made use of in all cases of fracture of 
the ribs, is to place strips of adhesive plaster about eight or ten inches 



A TREATISE OX FRACTURES. 355 

in length and one and a half or two inches wide, parallel with the 
course of the ribs, and covering a few inches above and below the 
fracture; each strip overlapping the preceding one by about two- 
thirds of its width. Compresses may be added to these, if neces- 
sary ; and they may be renewed whenever they become relaxed. If 
properly carried out, this plan is quite as efficient as any other in 
keeping the parts at rest and allaying pain.] 

Some precautions are to be observed in thus confining the chest. 
If the patient, from emaciation, cannot well endure such pressure 
over the bony prominences, the exposed points should be guarded 
by compresses or by cotton. In fractures of the lower ribs, the ap- 
paratus should not be applied over the ribs themselves, as this can- 
not be done without making undue pressure on the abdomen. For 
myself, I make it a general rule not to go below the xiphoid car- 
tilage ; it matters little that the bandage does not press directly over 
the fracture, the immobility of the ribs in the middle necessarily 
involving that of the rest. 

But the most essential point is to regulate the degree of pressure. 
Fabricius Hildanus wrote to Hagenbach, "Arcta ligatura quantum 
sit periculosa in fracturis costarum, alias coram ex me intellexisti." 
J. L. Petit has related a case of simple contusion without fracture, 
treated by a very tight bandage ; he attributes to this bandage, not 
without probability, an internal inflammation which terminated in 
suppuration and death- I have seen several surgeons keep a tight 
bandage around the chest even when symptoms of pneumonia were 
present ; this is an exceedingly dangerous practice. 

The only guide for the practitioner as to this point is the persist- 
ence of the pain. If it yields to slight pressure, go no further; if 
the patient feels better for strong constriction, increase it till he is 
satisfied; if the pain is entirely gone, we may dispense with the 
bandage without inconvenience; if it persists in spite of the band- 
age, and much more if it is increased by it, the latter is useless and 
injurious. 

The rule thus given for simple cases, is not less applicable to such 
as are complicated. Thus in persons with chronic affections of the 
chest, asthma, bronchitis or phthisis, we should not aggravate this 
with a view of remedying the external malady. If the fracture 
gives rise to pain, apply the apparatus moderately tight, letting the 
patient be the judge. If he feels better, we should continue; if he 
complains of annoyance, or of suffocation, we should diminish the 
pressure or even remove the whole apparatus. 

It may be however that a man with his chest crushed cannot 
support the constriction of the ordinary bandage, and yet complains 
much of the pain of the fracture. Alanson has recommended in 
such cases a flannel bandage, as constituting a soft and elastic com- 
pressor, capable of yielding, and easily accommodating itself to the 



356 A TREATISE ON FRACTURES. 

alternate movements of the chest. I have sought to obtain immo- 
bility of one side only of the chest, with long adhesive strips ar- 
ranged in a certain way; thus, starting with one strip at about the 
anterior extremity of the seventh rib on the right side, I brought it 
round the left half of the chest, up under the left scapula to above 
the right shoulder; thence a second time round the thorax to the 
left, to terminate at last at the level of the right iliac crest. The 
costal respiration was notably hindered on the left side, while it re- 
mained entirely free on the ( right. Perhaps by fastening the arm 
against the ribs we could gain still more ; if not, we must be satisfied 
with rest in bed, leaving the chest free. 

But when the displacement, although apparently slight, gives rise 
to intense pain, unappeased by the bandage ; when the depression of 
a splinter or of a fragment irritates the lung, and besides the pre- 
sent pain threatens serious visceral inflammation, reduction is indi- 
cated, and the question is only as to the choice of means. 

I shall only say of cups and drawing plasters, that they are clearly 
useless. Strong inspirations, or efforts made by the patient under 
our direction, are the most rational means, and may at least be tried 
without risk. I have seen a bone-setter who made the patient blow 
strongly into a bottle, applying his lips around the neck of it; this 
was nothing but a simple effort. M. Lionet has recently communi- 
cated to the Societe de Chirurgie a plan which has several times 
been found useful in immediately allaying the pain, viz., squeez- 
ing the patient strongly from before backward, so as to depress the 
sternum ; directing him to make an effort at the same time. I have 
tried this by pushing the patient against a wall, with his back to it, 
and bearing with my hand on the sternum; and in some cases when 
no displacement was apparent, I actually succeeded in thus allaying 
the pain. Probably these fractures were of the internal table ; and 
in my experiments on the dead body, I have seen how such pressure 
might be useful. In the memoir, previously quoted, I said: "When 
there is an incomplete fracture of the internal table, with depression 
of the external one, compression at both ends of the rib diminishes 
somewhat the depression, but does not entirely efface it; whenever I 
have sought to gain by increasing the pressure, I have only succeeded 
in rendering the fracture complete." The effort made at the same 
time by the patient doubtless aids in disengaging the points of the 
fragments, entangled in the pleura; but however this may be, it is 
useful to maintain the reduction by applying compresses to some 
degree of thickness over the sternum, and surrounding the chest with 
a strip of lead-plaster; it is the only case in which it seems to me that 
J. L. Petit's ideas may be properly acted on. 

Ravaton succeeded in another way, but still by a sort of effort. 
A miller, having had a heavy wagon pass over his chest, had three 
ribs broken, which touched one another, says the author, by their 



A TKEATISE ON FRACTURES. 357 

angles. Ravaton made him suspend himself by two sticks under his 
armpits; immediately the pain, which was very severe, ceased en- 
tirely, and the ribs assumed their proper levels. Ravaton explains 
this by the tension of the intercostal muscles; but whatever the 
theory may be, the fact remains. 

When considerable depression exists, such means would undoubt- 
edly be quite useless ; and if the sternal fragment were driven in, 
as generally occurs, pressure on the sternum would be positively 
injurious. I have seen in my experiments on the dead subject that 
by carefully pressing the fragment which remains in place, till it 
touches the one which is driven in, the serrations of the one may 
become interlocked with those of the other, — and then on removing 
the pressure from the former, its elasticity brings it to its level and 
at the same time elevates the other. In the living subject a strong 
effort, conjoined with this manoeuvre, aids it; moreover, experience 
has shown me that it is not even necessary to completely elevate the 
depressed fragment in order to allay the pain. Doubtless then we 
give relief by disengaging the points from the tissues. I have pub- 
lished in my Memoire two remarkable instances of success with this 
method ; and since then I have been equally fortunate with it in two 
other cases. 

Lastly, graver conditions may be presented, calling for more en- 
ergetic measures in order to reduction. Soranus, supposing the 
pleura to be wounded by the bony point, laid the rib bare by inci- 
sion, passed in a guard to protect the pleura, and then cut off and 
removed the sharp ends. Duverney recommends cutting through 
the intercostal space below the fracture, so as to introduce the finger 
into the chest and push out the depressed portions. Goulard devised 
a double hook for the same purpose ; Boettcher proposed the use of 
the elevator; Callisen, to facilitate the use of the elevator by an 
incision. But here the plans are more numerous than the cases ; 
I have found no one but Rossi who mentions in one place having 
had occasion to remove a piece of a rib ; and he elsewhere speaks 
of having removed the posterior extremity of the ninth rib by means 
of a lever introduced through an incision in the next intercostal 
space below; he gives no further details. For my own part I have 
never met with such indications ; but I should much prefer using a hook 
curved like a tenaculum, carefully inserted over the upper border of 
the rib and carried along its inner face, so as without incision to pry 
it up as with an elevator. 

AVhen we have succeeded in raising up, or in merely disengaging, a 
depressed portion of a rib, it is important to prevent the displace- 
ment from recurring, which would almost certainly involve a return 
of the pain. Too tight a bandage, or a bad position, may give rise 
to this. "We may try the application of a bandage according to the 
rules before given ; but if we find it useless or injurious, we must 



358 A TREATISE ON FRACTURES. 

leave it off. The patient should lie as he finds it most convenient; 
instinct being often a better guide than the surgeon. Experiments 
on the dead body show us clearly that when the sternal fragment is 
driven in, lying on the back or on the injured side tends to elevate 
the posterior fragment, and vice versa; whence we may to some ex- 
tent judge as to what position will be most suitable. But sometimes 
also other circumstances occur in the living subject to set aside our 
preformed ideas; and on the whole the best position is that which 
causes least pain; only when this is once found it should be main- 
tained by the patient, at least for the first few days. 

A simple fracture of the ribs does not generally make rest in bed 
necessary; a fracture with displacement or with any complication 
demands it until such symptoms shall have disappeared. I need not 
here go over the treatment of the visceral inflammations which some- 
times complicate these fractures; but a few words must be said con- 
cerning traumatic emphysema. 

When the emphysema is very marked, the greatest surgical autho- 
rities unite in advising incisions into the pleural cavity, in order, they 
say, to empty the chest. There is no doctrine at once more un- 
founded and more dangerous ; this operation was but once performed 
by Abernethy, and the patient died from it. When the emphysema 
is limited to the trunk, nothing need be done; even when affecting 
the whole body, unless enormous, it will pass off of itself; and lastly, 
in those extremely rare cases in which it distends the integuments 
inordinately, a few punctures of the skin with a lancet or trocar suf- 
fice to give exit to the excess of air, and to favor the absorption of 
the rest.* 

* Malgaigne, Du traitement des grands emphys&mes traumatiques ; Bull, 
de ThtrapeiUique, June, 1842. 



CHAPTER VII. 

FRACTURES OF THE STERNO-COSTAL CARTILAGES.* 

These constitute, so to speak, quite a modern form of injury. 
Zwinger made it out clearly in the dead subject in 1698; but the 
fact -was entirely forgotten until 1805, when instances were observed 
simultaneously by Lobstein at Strasbourg and by M. Magendie at 
Paris, f 

These lesions are extremely rare. M. Magendie saw five instances 
of them in the short space of two years; but this was one of those 
extraordinary coincidences which sometimes occur in hospitals. Lob- 
stein saw but one case; most surgeons who have mentioned the lesion 
have likewise seen it but once; for my own part, I have only seen 
three instances in which it was clearly made out. I find but one 
reported among the 2328 cases at the Hotel-Dieu; it is omitted in 
all the statistics of foreign hospitals; and hitherto has been hardly 
noticed but by French surgeons. At most we can connect with this 
subject what Sir A. Cooper says of separation of the ribs from their 
cartilages by external violence; which is really only one variety of 
this fracture. 

I have observed it in a boy of seventeen and in a man of sixty- 
three; it occurs therefore both in youth and in quite advanced age. 
Its causes are very various ; such as a direct blow, the passage of a 
carriage-wheel over the body, or a fall from a height. In these latter 
cases the fracture may be produced indirectly ; in the dead body I 
have obtained a fracture, quite manifestly indirect, of the cartilage 
of the fifth rib on the right side, by violent pressure on the sternum. 

[M. Broca is quoted in the Brit, and For. Med.-Ohir. Review, Oc- 
tober, 1856, as reporting to the Societe Anatomique a case in which 
the sixth, seventh and eighth cartilages were ruptured by muscular 
action. The patient, a porter, had a sack of peas on his shoulder, 
when another was suddenly laid upon him. The weight bore him 

* Malgaigne, Recherches sur les fract. des cartil. sterno-costaux ; Bull, de 
TJi^rapeutique, April, 1841. 

f Lobstein, Compte rendu d la Faculty de M6d. de Strasbourg, etc., 1805, 
p. 24 ; Magendie, Mem. sur les fractures des cartilages des cotes ; Bibliotheque 
Medicate, tome xiv, p. 81. 

(359) 



3G0 A TREATISE ON FRACTURES. 

forward, and m raising himself against it he sustained the injury. 
The termination of the case is not stated.] 

According to the small number of cases known, the cartilage of 
the eighth rib seems more exposed than any other, and next to this, 
those immediately above it. I shall mention in connection with frac- 
tures of the sternum, one involving the cartilage of the first rib. 
Most commonly only one cartilage is broken; M. Magendie has seen 
three, and M. Leudet five, at a time; but these were from severe 
falls, producing other frightful injuries. 

[A case occurred in the summer of 1855, at the Pennsylvania 
Hospital, in which the sixth and seventh cartilages on the right side 
were broken entirely through at about an inch from their sternal 
connections; there was no displacement, and the fracture was not 
detected until after death. The injury was received by a fall from 
a wharf, the chest striking on the edge of a boat; the colon was rup- 
tured, and the man died in a few days of peritonitis. The peri- 
chondrium was entire in the sixth cartilage, but broken through 
anteriorly in the seventh.] 

The essential peculiarity of this fracture is, that it is always even 
and perpendicular, never oblique or irregular. Generally there is 
overlapping; and most commonly the inner or sternal fragment is 
in front of the other. Hence was derived a theory, ascribing the 
displacement to the action of the triangularis sterni muscle upon 
the costal fragment, when unfortunately Delpech met with the op- 
posite displacement; since which M. Velpeau also has seen two such 
cases.* Delpech suggests that this depends on the seat of the frac- 
ture; that when it is close to the sternum, the sternal fragment 
passes forward, and when close to the rib, the costal fragment does 
so. To overthrow this opinion it suffices to recall that in rupture of 
the cartilage even at its place of union with the rib, as described by 
Sir A. Cooper, the cartilage projected forward. I have made nu- 
merous experiments as to this point on the dead subject; and al- 
though the results obtained were not always the same, it has yet 
seemed to me that the displacement is due to the elasticity of the 
ribs and cartilages more than to any other cause, and that the va- 
rieties of it depend mainly on the patient's position. Thus, when 
the subject is laid on the side on which the cartilages have been 
divided, the ribs are pushed by the surface on which the thorax lies, 
so as to make the outer fragment project forward; laying it on the 
sound side makes the inner fragment prominent; and this form of 
displacement occurs also when the patient is sitting or standing up. 

I repeat, however, experiment gives us sometimes very different 
results, which it is very hard to explain. Sometimes there is no 
very perceptible displacement, and a specimen in the Muse'e Dupuy- 

* Yelpeau, Anat. Chirurgicale, third ed., tome i, p. 355. 



A TREATISE ON FRACTURES. 361 

tren shows a fracture of this kind consolidated; sometimes the dis- 
placement is only in the thickness of the cartilage, whether forward 
or backward; sometimes, finally, there is actual overlapping, which 
is here certainly not due to muscular action. I am however very 
far from denying the influence of the muscles in the living subject, 
and it would appear to me especially incontestable in one of M. Ma- 
gendie's cases, in which three cartilages being broken at once, the 
fragments overlapped about an inch, and could not be reduced even 
after death. 

[In the case alluded to as seen by me at the Pennsylvania Hos- 
pital, there was no displacement, although the blow causing the in- 
jury must have been a very severe one; and from the shape and 
relations of the cartilage it would really seem impossible for either 
of the other causes o$ displacement to affect the fragments to any 
considerable degree.] 

For the rest, this fracture is not of itself serious. The fragments 
are soon enveloped in a sort of ring of plastic lymph which at length 
ossifies; it is exactly analogous to provisional callus, but here re- 
mains, becoming definitive; and on sawing through one of these 
fractures longitudinally, we find this ring sending in between the 
broken ends an osseous lamella which at once unites and separates 
them. This is, at least, what has been hitherto observed; perhaps 
in young subjects union may take place differently, and in several 
experiments on dogs, having cut the cartilages by subcutaneous in- 
cision, I found them after fifty days united exteriorly by fibrous or 
fibro-cartilaginous tissue, without any trace of ossification. 

The diagnosis may remain obscure when there is no perceptible 
displacement. A man aged 23 had had his chest caught between 
two carriage-poles; one pressed on the left side, at the level of the 
xiphoid appendix, a little in front of the transverse diameter of 
the thorax, and the other on the right side, at the same level, and a 
little posterior to that diameter. Severe pain was at once felt at the 
costal extremities of the seventh and eighth cartilages on the right 
side, increased by inspiration and especially by pressure; no dis- 
placement was perceptible. I presumed that the cartilages were 
broken. Here the diagnosis was only a probable one; displacement 
only could give it some certainty, particularly if one or the other 
fragment could be depressed at will. 

To perform reduction, it sometimes suffices to press upon the pro- 
jecting fragment; sometimes, when there is overlapping, we must 
try to remedy it by forcible inspirations. The fragments once being 
end to end, the only indication is to prevent displacement in their 
thickness, without which no overlapping can occur. But this most 
surgeons have regarded as impossible. Sir A. Cooper recommends 
putting over the fractured cartilage a piece of moistened pasteboard, 
so as to bear also on the corresponding rib and on the one next to it 



362 A TREATISE ON FRACTURES. 

on Bach side; this pasteboard, says he, drying on the chest, assumes 
the exact form of the parts, hinders them from moving, and offers 
the same support as a splint in other fractures; it is to be fixed by 
a flannel bandage around the thorax. 

I do not know whether Sir A. Cooper ever used this apparatus; 
but on the one hand, if the pressure were sufficient, I should dread 
the occurrence of gangrene of the skin, and on the other I do not 
see how the fragments are supported during the time required for 
desiccation. Besides, the relations of the fragments being changed 
by changes in the position of the body, we must act on both at once, 
with a force equal in all positions, even in all the motions of respira- 
tion. I have succeeded in this with the simple English truss for in- 
guinal hernia. This, as is well known, is formed of an elliptical 
brace going a little more than half-way round the body, and furnished 
at its extremities with pads looking toward one another. The pos- 
terior pad, acting on the convexity of the ribs, pushes the outer frag- 
ment forward; the anterior pad pushes the inner fragment back- 
ward; hence we need only make the pads of suitable width and 
firmness, and the brace being kept in place by the double pressure, 
there is no need of any circular compression of the chest. 

A young man of seventeen struck himself in running, against the 
balustrade of a staircase, the blow falling at the right side of the 
sternum, above the xiphoid cartilage. He came to me ten days 
afterwards ; I detected a fracture of the cartilage of the fifth rib on 
the right side, about an inch from the sternum. When he stood up, 
the inner fragment presented a slight projection forward, which dis- 
appeared under slight pressure or by a full inspiration ; it increased 
when he lay down on his left side, diminished a little when he lay on 
his back, and diminished still more when he lay on his right side, 
without however absolutely disappearing. I tried at first a body- 
bandage, which proved useless; and on the fourteenth day I applied 
the truss spoken of, previously covering the part with the softened 
pasteboard recommended by Sir A. Cooper. Some days afterwards, 
I was obliged to remove this splint, which had already bruised the 
subjacent skin. I substituted for it a very soft compress; I even 
fitted to the anterior extremity of the truss an india-rubber air-pad, 
to lessen the pressure ; from that time things went on better ; the 
patient remained up the whole day, lay at night on either side, and 
when I removed the apparatus on the twentieth day, union was 
perfect and without the least inequality. 



CHAPTER VIII. 

FRACTURES OF THE STERNUM. 

These fractures are extremely rare ; but one case occurred at the 
Hotel-Dieu in the course of eleven years; and of 1901 fractures 
observed in the Middlesex Hospital, Lonsdale noted but two of this 
bone. Hippocrates does not mention them ; they are however spoken 
of by Celsus, and distinguished by Soranus into two varieties. 

Modern observations oblige us to admit other forms. We find in 
Ploucquet two cases of longitudinal fracture quoted from Kraemer 
and Meyer; it appears that the latter did not reunite. I have not 
been able to trace these up ; but the following case, given by Barrau, 
will afford a sufficient idea of this sort of injury. 

A mason, aged 60, was thrown from a scaffolding by the falling of 
the wall at which he was working, and was taken out from the ruins, 
where several large stones lay upon one side of his chest. The 
sternum was fractured lengthwise, the fragment on the right side 
driven in eight or ten lines, the other slightly prominent. To reduce 
it, Barrau had the right arm drawn aside and backward, and strong 
pressure made on the middle portion of the true ribs of the same 
side, from before backward, in order to carry the depressed fragment 
outward and forward, while on the other side he pressed gently on the 
salient portion to restore it to its natural level. The reduction was 
maintained by a tight body-bandage, bearing on two compresses ; one 
of these, wide and thick, was applied over the most prominent part 
of the ribs on the right side ; the other, oblong, over the left portion 
of the sternum. The patient was cured in six weeks; but it is not 
stated whether any deformity remained.* 

I know of no other instance of longitudinal fracture; whence we 
may judge of its rarity. I have recently observed another form per- 
haps still rarer, for I have never seen it mentioned anywhere; it 
would rank among splintered fractures. 

A man of sixty-three was upset by a dray, the wheel of which 
went up on the left side of his chest, but not getting over the trunk, 
passed off on to the left arm, which however was uninjured. The 
next day the man came to the hospital; a quite notable swelling 

* Barrau, Bis. sur Us fract. du sternum, Tliese inaug., Strasbourg, 1815. 

(363) 



3G4 A TREATISE ON FRACTURES. 

occupied the upper sternal region; and the first piece of this bone, 
-with the cartilage of the second rib on each side, made so marked a 
prominence in front that I thought I had to deal with a luxation, or 
with a transverse fracture with overlapping. I tried various manoeu- 
vres to accomplish reduction, but in vain; effusion occurred in the 
plenra ; an abscess formed above the fracture, and the patient suc- 
cumbed on the thirty-third day. At the autopsy, a fracture was 
found in the semi-ossified cartilage of the first rib on the left side, 
and also in the second, third and fifth ribs of the same side; these 
had not been suspected at all. The sternum was broken transversely, 
at the level of the third intercostal space, the upper fragment being 
slightly inclined backward; this fracture also had escaped notice. 
Lastly a fracture, situated above and to the left, detached from the 
bone as if with a knife, a sort of scale, the base of which reached 
from the fourchette to the level of the second costal cartilage, com- 
prising all the left sterno-clavicular articulation, and the cutting 
edge of which was at the anterior face of the bone; the abscess had 
formed at the seat of this fracture. 

Now how was this mistake in diagnosis made ? The swelling had 
something to do with it ; again, there was naturally a prominence of 
the upper part of the sternum; and lastly, the inclination backward 
of the upper fragment in the transverse fracture had brought still 
further forward the cartilages of the two second ribs and the articu- 
lation of the first two pieces of the sternum, which were not fused. 

This is all I have to say touching these fractures. It remains for 
us to examine transverse fractures of the sternum, which are the 
most common of all, and the only ones treated of by most authors. 
In general they are nearly transverse, although this word must not 
be taken too strictly. In Figs. 11 and 12 is seen a fracture of the 
sternum found by M. Huguier in the body of a woman; Fig. 11 
shows the edge of the lower fragment in front, by no means regu- 
larly transverse; and in Fig. 12 a vertical section of the bone shows 
quite marked inequalities in its thickness. MM. Manoury and Thore 
saw an oblique fracture so disposed that the lower fragment was 
bevelled at the expense of its posterior face. In the subject whose 
history has just been given, the second fracture, nearly transverse at 
the anterior surface of the bone, had such a direction toward the 
other surface, that the upper fragment terminated in an angle at the 
expense of the lower fragment. I have seen another fracture in the 
living subject, describing a slight curve concave superiorly. These 
minor varieties are however unimportant. 

They are produced by either direct or indirect violence, or even 
sometimes by muscular action. The direct causes are most fre- 
quently such as the caving in of a bank of earth, the passage of a 
wheel over the chest, the blow of a carriage-pole; in a word, some 
enormous force. A case related by Duverney shows however that 



A TREATISE ON FRACTURES. 365 

this fracture may be caused by much slighter violence ; it was that 
of a nine-pin player who, bending forward to watch his ball, fell on 
a large stone, and was taken up dead, with a fracture of the sternum. 

The indirect causes are far more curious to study. These are, 
first, falls on the back, the principal example of which is quoted from 
David, but does not properly belong to him, and is rather a luxation of 
the two first pieces of the bone than a fracture. Sabatier has related 
another case, recognised as a fracture in an autopsy, although it also 
was between the two portions of the sternum. But a last case, due 
to M. Rollande, removes all doubt as to the reality of this cause. A 
woman aged 63, fell backward from a certain height, struck her back 
against the edge of a seat, and thus sustained a transverse fracture 
of the sternum at about its middle.* 

Next come very various falls, as on the buttocks, on the feet, on 
the head. M. Cruveilhier saw a man who, having fallen a distance 
of twenty feet upon his buttocks, presented no lesions except im- 
mense contusion at the part struck, and a fracture of the sternum. 
In a case reported by M. Cassan, the fracture was produced by a 
fall from the third story on the feet first, and then on the back. 
MM. Manoury and Thore have cited an analogous case ; it was that 
of a quarry-man who fell from a height of twelve or fifteen metres, 
lighting on his feet first, and by a second impulse striking his back 
and head. Lastly, I have read in an English journal an account of 
a young man of twenty-two, admitted in 1832 to St. George's Hos- 
pital; the fracture had resulted from his falling head-foremost off a 
hay-wagon ; his head was doubtless flexed forward when he struck 
the ground, since it had this position after the accident.")* 

What is the mechanism of these fractures ? When caused by falls 
on the back, they are ascribed to muscular action ; and M. Cruveilhier 
applies the same theory when they result from falls on the buttocks. 
An attentive study of the facts leads us to different conclusions. In 
some very rare cases, the patient having fallen on the back, the 
fracture occurs without overlapping, perhaps even with slight sepa- 
ration of the fragments; it appears that it is in fact due to forcible 
flexion backward of the trunk, subjecting the sternum to violent dis- 
tension ; only it may be doubted whether the rupture is actually 
caused by the muscles pulling in opposite directions, or by the forci- 
ble separation of the upper from the lower ribs, carrying with them 
their respective portions of the sternum. But in the majority of 
cases, on the contrary, the fracture results from forcible flexion 
forward of the trunk, or at least from a shock tending to approxi- 

* Sabatier. Mem. vw la fract du uterinum, ; M6m. de VInstitut, an vii, tome 
ii. p. 115: Rollande, Bulletin de Th£rapeutique, tome vi, p. 288. 
t Cruveilhier, Bull, de la Soc. Anatomtque, June, 1826 ; Cassan, Archives de 
"■. January, 1827; Manoury et Thore, Gaz. Medicate, 1842, p. 361; 
co-Chdr. Review, 1632, vol. xx, p. 536. 



866 A TREATISE ON FRACTURES. 

mate the two ends of the sternum. This was manifest in the patient 
who Pell with his head bent forward. In M. Rollande's case, the 
blow, although falling upon the spine of the last dorsal vertebra, had 
certainly induced flexion forward, since the upper fragment of the 
sternum was driven in behind the other, and the head was bent for- 
ward on the chest. 

Tim-, in fractures by counter-stroke, flexion of the head and over- 
lapping of the fragments indicate a fracture by flexion forward of 
the trunk, while want of overlapping, or separation of the fragments, 
are peculiar to fractures by flexion backward. Fractures arising 
purely from muscular action range themselves in this latter category 
by their mechanism as well as by their phenomena. 

Chaussier saw two such cases from efforts in child-birth, in primi- 
parse twenty-four or twenty-five years of age ; both, at the moment 
of the rupture, had the head thrown strongly backward, and were 
resting on the arms and heels. In one the fragments retained their 
place; in the other they were slightly separated. [A case occurring 
under exactly the same mechanical conditions as those just described 
may be found in Hays' Am. Journ. of 31ed. Sc. for July, 1858, 
(p. 272,) quoted from an Italian journal; it concerned the upper 
piece of the bone, and terminated in recovery. Another is there 
alluded to, as having been observed in France, but with a fatal result.] 
The throwing back of the head occurred in a case of another kind, 
related by M. Faget, professor in Mexico. A mountebank, display- 
ing his strength in a public place, had leaned backward to raise up 
with his teeth and hands a considerable weight ; all at once he felt 
severe pain in the sternal region, and fell over with a fracture of that 
bone.* 

There is, however, a remarkable peculiarity in these instances : 
all three of them were seated above the articulation of the first piece 
of the sternum with the second. I do not know whether it would 
be so in fractures from, falls with the trunk bent backward; the cases 
are not given precisely enough for us to judge, and the point demands 
further investigation. 

We must not forget another kind of fracture by muscular action, 
which would be produced by sudden contraction of the diaphragm, 
and thus would be analogous to certain fractures of the ribs, before 
alluded to. I know of but one such case. A locksmith, aged 32, 
suffered from scirrhus of the stomach, causing frequent vomiting. 
One day he complained of pain in the sternal region, the cause of 
which could not at first be imagined ; afterwards a transverse frac- 
ture was detected in the upper third of the sternum, and the autopsy 
verified this diagnosis. The bone seemed diseased an inch below the 

* Chaussier, Revue MMicale, 1827, tome iv, p. 260 ; Roger Dubos, Mai du 
sternum, These inaug., Paris, 1835. 



A TREATISE OX FRACTURES. 367 

fracture, but sound at the precise seat of it.* It may be seen that 
from its seat this fracture would resemble those induced by flexion 
of the trunk. 

All fractures by counter-stroke or by muscular action are simple, 
and divide the sternum into two fragments only. Direct causes 
sometimes produce single fractures likewise ; but they frequently 
break the bone into splinters ; or perhaps to the main fracture are 
added fissures of greater or less extent ; or lastly, the bone may be 
broken at two different points. Duverney saw a fracture with splin- 
ters, caused by falling on a stone; Pluto had occasion to treat one 
with three splinters, from a bayonet wound; La Martiniere one with 
four splinters, a ball having passed back of the bone, etc.f On the 
other hand, there is in the Muse'e Dupuytren a transverse fracture 
with a fissure two or three centimetres long, limited to the outer 
table; and I have before me an analogous specimen, except that the 
fissure occupies the whole thickness of the bone. As to fractures 
dividing the sternum at two points, I know of no other instance than 
the one related above. 

Quite often, also, fracture of the sternum is complicated with 
fractures of other bones. In falls on the back it is the vertebrae, 
and especially their spinous processes, which are found broken ; in 
cases of direct violence it is the costal cartilages, or the ribs ; not to 
speak of other complications. 

It will readily be understood that fractures from direct violence 
cannot have a seat so well-defined as others. It is, however, remark- 
able that they have never been seen to affect the upper piece of the 
bone; and the lowest piece seems likewise exempt. I saw in 1813, 
at the Hopital St. Antoine, a marble-cutter, aged 43, who ten years 
before had had the sternum broken by a blow from a carriage-pole ; 
the fracture was seated on a level with the upper edge of the carti- 
lage of the fifth rib ; I know of no other instance of a fracture situ- 
ated so low down. 

The symptoms in every fracture of the sternum are at first severe 
pain at the seat of the injury; one of Chaussier's patients heard at 
me time a crack which made her say that something had pro- 
bably given way in her chest. This pain is increased by pressure, 
or by coughing, sometimes even by the mere effect of ordinary costal 
respiration ; it diminishes when the ribs and sternum are kept at 
rest ; sometimes, lastly, almost immediately after the accident it dis- 
appears, and does not recur. When the fracture is the result of a 
direct blow, the integuments offer generally traces of contusion, and 

■.'Me des Bxkntaux, M;irch 20, 1830. 
\ Pluto, Journa </< _)/<•</. Miiit., par Dehorne, tome i ; and Diet, des Sciences 
M&diccUes, art. Sternum; La Martiniere, M6m. sur Vopir. du trypan au ster- 
num ; Acad, de Ghirurgie^ tome 4, p. 545. 



3G8 A TREATISE ON FRACTURES. 

eeohymosis ensues cither at once or within a few days ; but this is 
not at all constant. We should expect, also, the occurrence of more 
or less swelling of the part; and the inflammation sometimes runs 
on to suppuration, either at the seat of fracture, or behind it in the 
mediastinum. 

Displacement brings with it other evidences, the clearer in propor- 
tion as it is more marked. It may indeed be very slight, imper- 
ceptible in the living subject, as in the case I have related; or it 
may be more pronounced, one of the fragments projecting by as 
much as half its thickness ; this is what is seen in Fig. 12 ; or the 
displacement in the direction of the thickness may be complete, and 
more or less overlapping may be conjoined with it. But what is ex- 
tremely remarkable is, that it is almost always the lower fragment 
which projects forward; I know of but one instance of the contrary ; it 
will be seen that then there was overlapping to an almost incredible 
degree. A man more than sixty years old was set upon and beaten 
with fists, and afterwards thrown into a hole thirty feet in depth. 
He fell on his back, and when examined was found to have a trans- 
verse fracture of the sternum at the junction of the first and second 
pieces, the latter being driven behind the former. Reduction was 
impossible ; the patient died on the eighth day. At the autopsy, 
Sabatier found the sternum fractured at the point mentioned, and 
the lower portion of the bone not only driven in, but also engaged 
behind the upper one to the extent of twenty-eight millimetres. 

It is remarkable that such shortening of the anterior wall of the 
chest so rarely induces bending of the trunk and of the head ; I 
have only twice found flexion forward of the head mentioned. 

When the fracture is simple and without displacement, crepitus is 
quite frequently wanting ; sometimes we may obtain it by pressing 
alternately on the fragments ; lastly, there are certain cases in which 
it is produced without any effort, by the mere movement of respira- 
tion. Mesnier, in 1702, observed this phenomenon, but in an old 
fracture, the fragments being carious and bathed in pus. Meek de- 
tected it in 1764, in a case of recent fracture, and with attending 
circumstances worth relating. The patient was an old man of 
seventy-four, who had had the sternum and the three lower true ribs 
on the right side broken by the passage of a carriage-wheel over 
them. The fragments rubbed on one another in respiration to such 
an extent that crepitation was audible ten paces off; on applying 
the hand to the chest, the lower fragment was felt to be pushed for- 
ward at each inspiration and drawn back at each expiration, so as to 
pass by the edge of the upper fragment in each direction ; the latter 
remained nearly motionless. The patient being unable to endure any 
apparatus, this noise could be heard for three weeks ; after which it 
ceased, and the fracture became so firmly united that its seat could 



A TREATISE ON FRACTURES. 369 

not be distinguished.* Sabatier lias related an almost exactly simi- 
lar case; so much so as to seem as if copied from the preceding one. 

Such are the symptoms of the fracture itself; but when it is pro- 
duced by a direct cause, other symptoms due to lesions of subjacent 
parts often come in as complications. Russel, Flajani, and Dupuy- 
tren have seen fractures of the sternum attended with emphysema, "j" 
Frequently patients are troubled with dyspnoea and spitting of blood, 
denoting more or less grave injury of the lungs. Lastly, when one 
of the fragments is driven in, the heart itself may be wounded. 
J. L. Petit found in an autopsy the heart merely compressed ; but 
Dupuytren saw the right ventricle torn in two-thirds of its thickness, 
and Duverney relates two cases of complete rupture of the heart. 
Lesion of the internal mammary arteries has been dreaded also; but 
hitherto I know of no instance of it. 

Apart from these complications, fractures of the sternum generally 
terminate favorably. One month would seem to be sufficient for 
consolidation; in one case the apparatus was removed on the twenty- 
third day without any inconvenience ; most surgeons have kept it on 
for about six weeks. It is but rarely that we can succeed in entirely 
correcting the displacement; such cases are however related, among 
which may be specially noted those of Meek and Sabatier. But 
even a considerable displacement does not of itself entail any serious 
inconvenience. My stone-cutter, in whom the upper fragment was 
driven in five or six millimetres, attended to his business for ten years 
without its giving him any trouble. M. Huguier's patient, with a 
displacement of which Fig. 12 gives an exact idea, was in no way 
incommoded by it. 

Must we not, however, admit there are exceptions? "I have re- 
marked," says J. L. Petit, "that a man was subject to a dry cough, 
with palpitation of the heart and difficulty of breathing, who had 
had the sternum driven in." Duverney speaks of a patient who was 
cured in six weeks, who, however, still continued in ill-health; Saba- 
tier' s patient had ever afterwards some difficulty in breathing. But 
the complications entirely account for these results. Duverney's pa- 
tient had two cartilages luxated, his symptoms had yielded only to 
several bleedings, and he was an octogenarian ; Sabatier's, from the 
effect of the external violence, had vomited blood ; these were cir- 
cumstances which could not but influence the results of their cases. 

The diagnosis is far from being always easy. In one of the cases 
observed by Chaussier, the fracture was only recognised on the sixth 

*Meek, Essays and Obs., Physical and Literary, of the Edinburgh Society, 
vol. iii, p. 535. Mesnier's case is in La Martiniere's memoir, already cited, 

t Russel, Obs. et recherches des m&d. de Londres, tr. into Fr., tome i, p. 287 ; 
Flajani, CoUezione d' Osservazioni, tome iii, p. 214; Dupuytren, Lecons Orales, 
tome ii, p. 215. 

24 



370 A TREATISE ON FRACTURES. 

day; in the other, only at the autopsy. This is explained by the 
nature of the causes, as in the patient whose fracture was the result 
of vomiting, and in whom it likewise remained undetected. But in 
Flajani's rase, the fracture was direct; the upper fragment was driven 
in, and yet the emphysema prevented its discovery till after death. 
F«>r my own part, as has been seen, I fell into a double error; I 
overlooked a second fracture, from being preoccupied with the first; 
and in this I was deceived as to its seat and direction. 

We must, then, so long as there remains any emphysema or swell- 
ing, abstain from affirming or denying the existence of fracture ; 
and if this is made evident by crepitation, we must still avoid pro- 
nouncing too soon as to its nature, and even as to the presence or 
absence of displacement. The sternum often presents congenital or 
accidental depressions which would closely simulate those caused by 
violence; only if there is notable overlapping, besides the depression 
in the sternum, we should have a nearly pathognomonic sign, to wit, 
the narrowing of the intercostal space corresponding to the fracture. 

The prognosis is generally simple and favorable when the fracture 
is a simple one ; its gravity depends on that of the complications. 
Still, even in the simplest fractures, the danger of suppuration merits 
special attention here ; among the few cases known, it occurred in 
five, viz., in Mesnier's patient, in Chaussier's two women, in the man 
whose fracture resulted from vomiting, and in my own patient. 

The indications for treatment vary according as there is or is not 
displacement. When the fragments remain in contact, we have only 
to keep the thorax at rest by means of a body-bandage, or better still 
by a wide strip of diachylon or lead-plaster. If the bandage cannot 
be endured, the patient should be kept on his back in bed, with his 
head low rather than high. For the rest, exactly the same rules 
apply here as in fractures of the ribs, as to the degree of pressure, 
the application of the bandage, and even the position of the patient. 
In the two cases, so nearly similar, of Meek and Sabatier, the patients 
experienced such difficulty of breathing as that no pressure could be 
borne ; they could not even lie down for any time, and for eight 
days they had to be supported in the sitting posture, either in bed or 
on a sofa, bending forward, and with the head resting on a chair well 
garnished with pillows. 

When the depression is simple, and without overlapping, the idea 
which first occurs is to press on the projecting fragment, to push it in 
to the level of the other ; we shall presently see that it has been pro- 
posed also to act on the fragment driven in, so as to raise it up. 
Unhappily the displacement, maintained at once by the intercostal 
muscles and by the differing elasticity of the ribs attached to the 
two fragments, does not always yield so readily as one would be led 
to suppose. Besides, when there is overlapping also, some kind of 
extension must be made on the sternum, and this bone affords of 



A TREATISE ON FRACTURES. 371 

itself no purchase. It has therefore been sought to act on the two 
fragments by means of the ribs, the shoulders, the head, and the 
spine. 

Paulus JEgineta, doubtless following Soranus, put a cushion under 
the patient's back, drew the shoulders backward, — acting thus through 
the clavicles on the upper fragment, — and pressed at the same time on 
the ribs of both sides ; this would tend to open the arc which they 
describe, and to carry their sternal extremity forward. A. Pare* says 
he once succeeded by this plan. In case of failure, Duverney adopt- 
ed another method ; he laid the patient on his side, putting some- 
thing hard beneath his ribs, and then pressed on the ribs of the oppo- 
site side, an assistant at the same time pushing inward upon the spine. 
Later surgeons neglected, perhaps too much, the idea of acting upon 
the ribs ; Aurran, placing a bolster under the back, pressed at once 
on the chin and on the pubis, so as to curve the trunk backward; 
Monteggia sought to draw the shoulders back, while he pushed against 
the spine with his knee ; in the patient at St. George's Hospital, 
throwing the head back strongly was sufficient to obtain complete 
reduction. But here I have a remark of some importance to make. 

Judging from the few cases published, reduction should be quite 
easy ; its maintenance alone should present any difficulty. I must 
say, however, that I have seen a recent luxation of the first piece of 
the sternum on the second, a lesion entirely comparable to a trans- 
verse fracture, which resisted all my efforts ; and in the only case in 
which the lower fragment was driven in behind the upper, reduction 
was likewise impossible. Perhaps overlapping constitutes more of 
an obstacle than mere depression ; perhaps also the tension of the 
skin over the sternum during the operative proceedings has deceived 
surgeons, making them too readily believe the reduction complete ; 
however it may be, it must at least be admitted that there are frac- 
tures with depression which are quite unmanageable, and for which 
various operations have been devised. 

J. B. Verduc was the first to propose making an incision through 
the integuments, and inserting an elevator into the depressed frag- 
ment, in order to draw it out to the level of the other. J. L. Petit 
advises the use of the elevator and of the trepan. Delpech thinks 
it would suffice to cut with a lenticular knife a portion of the anterior 
fragment. Quite recently M. Nelaton has suggested that it might be 
practicable to introduce, through a narrow opening alongside of the 
bone, a blunt hook to raise the depressed fragment. I had myself 
had another idea, which was to carry through the skin to the end of 
the anterior fragment a point, by means of which it could be pushed 
either down or up to the level of the other ; but the sternum is too 
soft in texture, and the instrument penetrates it too easily. 

Of all these means, the elevator would seem the simplest and the 
least dangerous ; but there are two circumstances which should make 



372 A TREATISE ON FRACTURES. 

the BurgeOD cautious, not only as to operations of this kind, but also 
as to the too tree use of ordinary methods of reduction. The first is 
the danger of suppuration, alluded to above, and the second is the 
difficulty of keeping up the reduction when obtained. 

La Martiniere has cited a case in which the elevator was employed; 
but the reduction so made was so insecure that it was deemed proper 
to leave the instrument in place, fitting a stick to it like a lever, to 
keep the fragments in position ; but death occurred too soon for us 
to judge of the success of this singular plan. 

Richerand had to deal with a depression of the upper fragment to 
the extent of a few lines merely; he applied over the lower one thick 
compresses, fixed by a very tight body-bandage and roller. The ap- 
paratus was renewed whenever it became loose ; at each dressing an 
assistant pressed strongly on the lower fragment, so as to keep it at 
the level of the other, and this was kept up for forty days ; but in spite 
of all his care there remained a hollow, and a projection of some 
lines. The surgeons of St. George's Hospital took much more mi- 
nute precautions ; they kept their patient with his head as far back 
as possible, his shoulders drawn back by a figure-of-8 bandage round 
both of them ; a pad was applied over the projection, and supported 
by a roller around the chest. The displacement was thus diminished, 
but not entirely overcome. In a patient treated at the Hopital 
Beaujon, in 1829, the fragments were easily reduced by simple pres- 
sure ; but it was so hard to keep them in contact that the bandage 
had to be tightened daily.* Lastly, in M. Rollande's case, the pa- 
tient was paraplegic, and certainly remained as completely at rest 
as possible ; yet the fragments, restored at first to their place, be- 
came somewhat deranged afterwards. 

I think therefore that although it is proper to attempt reduction, 
it is wrong to persist in endeavoring to make it complete. As to 
the means of retention, unless the displacement tends strongly to 
recur, the body-bandage, or rest in bed, may be sufficient; if not, 
we may exert moderate pressure over the anterior fragment by means 
of thick compresses fixed with a strip of diachylon, the patient hav- 
ing a cushion under his back so as to bend the trunk backward, and 
his head being at least as low as his chest. The position of the 
head is especially important; several times displacement has been 
seen to recur from its being inclined forward. Perhaps we should 
succeed still better by fixing the shoulders upward and backward 
with Brasdor's corset, or with one of the apparatuses modeled upon 
it, of which we shall speak when on the subject of fractures of the 
clavicle. 

J. L. Petit and La Martiniere, and after them Boyer, recommend 
trepanning, so as to give an issue to the blood effused behind the frac- 

* Journal des Progr&s, 1830, tome ii, p. 258. 



A TREATISE ON FRACTURES. 373 

ture. It is not worth while to refute this idea. The sternum should 
not be thus meddled with unless pus is collected behind it, and the 
bone itself is carious. In one case of gunshot fracture, La Mar- 
tiniere exposed the bone, and by means of the elevator removed four 
splinters, amounting in size to about that of a crown-piece. Pluto, 
in an analogous case, limited himself to removing one splinter and 
elevating the rest ; long before this, Mesnier had applied the trepan 
to destroy a caries of the fragments, and thus opened an abscess 
behind them. These three patients all finally recovered; and in 
analogous circumstances the same plan should be adopted. 

I say nothing of visceral inflammations, which should be ener- 
getically combated, but the discussion of which does not properly 
belong here. 



CHAPTER IX. 

FRACTURES OF THE CLAVICLE. 

I PASS from fractures of the sternum directly to those of the cla- 
vicle, partly on account of the anatomical relations of the two bones, 
but mainly because they present, as was before said, some indications 
in common. 

These fractures may without hesitation be ranked among the most 
frequent, since of 2358 fractures they numbered 228. They occur 
indifferently in all seasons; I find but three more in the summer 
than in the winter months. But sex and age exert an influence not 
to be passed over. 

Among the 228 cases, only fifty-eight were women; — about one- 
quarter. This proportion remains nearly the same for the period of 
life between fifteen and sixty-five years; but after this, singularly 
enough, the clavicle seems to be oftener broken in women than in 
men ; in fact, eleven out of eighteen cases were women. I have 
no precise data whereby to establish the proportion of the sexes in 
early life ; all that I can say is that at the Hopital des Enfants there 
are more fractured clavicles in boys than in girls. 

As to ages, before fifteen our table shows but six fractures, and 
over sixty years only thirty-one. But it must be observed that at 
the Hotel-Dieu children are only received in exceptional cases; and 
at the Hopital des Enfants fracture of the clavicle is one of the 
most common of all fractures. The clearest result from these figures 
is therefore that it is comparatively rare in old age, and its frequency 
in youth and in adult age accords very well with its equal frequency 
in summer and in winter. 

The determining causes likewise show the reason of these statisti- 
cal results. Sometimes they are direct blows, the fall of a beam, a 
blow with a stick, more rarely a fall in which the clavicle strikes 
against some object; now men are more exposed to such accidents 
than women are, and adults more than old people. 

Sometimes, and perhaps more frequently, the causes are indirect, 

as a fall on the hand or on the elbow, and the most frequent cause 

of all is falling upon the shoulder. Now as I shall show hereafter, 

falls on the wrist are more apt in women to cause fracture of the 

(374) 



A TREATISE ON FRACTURES. 375 

lower end of the radius, and in old age falls on the shoulder most 
commonly occasion fracture of the cervix humeri. 

The clavicle may be broken at any point in its extent. Is there 
any relation between the nature of the cause, and the seat of the 
fracture? M. Thouverey has made some experiments in order to 
solve this problem;* but these attempts, made on the skeleton and 
under entirely artificial conditions, cannot even furnish the com- 
mencement of a demonstration. They must be repeated upon whole 
subjects; yet still, the clavicle is acted on by so many muscles which 
in the living subject vary its position in a manner which cannot be 
imitated after death, that such experiments deserve but limited con- 
fidence. 

I shall discuss successively : (1) fractures of the body of the bone ; 
(2) fractures of its sternal extremity; (3) fractures of the acromial 
or scapular extremity; (4) fractures of both clavicles at once. 

§ I. — Of Fractures of the Body of the Clavicle. 

These fractures, beyond comparison the most frequent of any in 
this bone, engaged almost exclusively the attention of surgeons down 
to the seventeenth century; and for them especially all the dressings 
were invented. 

They may be produced by direct or indirect causes. The mechan- 
ism of the first needs no explanation; for the others, as in falls on 
the elbow or on the hand, but more particularly in falls on the point 
of the shoulder, it has been said that the bone, being pressed be- 
tween the ground at one end and the weight of the body acting 
through the sternum on the other, tends to bend at its point of 
greatest curvature, so that the fracture occurs either at the middle 
or in the outer third of the bone. This is a theoretical view, some- 
times doubtless confirmed practically, but often contradicted by the 
different seat or direction of the fracture. Thus there is seen in 
Fig. 17 a fracture caused by a fall from a second story; it is cer- 
tainly indirect; everything would lead us to suppose that the fall 
took effect on the point of the shoulder; and yet the extreme ob- 
liquity of the fracture forbids our assuming here any increase of the 
normal curvature. 

Other circumstances besides falls may also give rise to indirect 
fractures. Xicod has related the case of an old woman who broke 
her clavicle in pushing forcibly the door of a cupboard ;f which may 
be compared with the case of fracture by falling on the hand. I 
have seen an incomplete fracture of the clavicle resulting from the 
re of a burden which slipped from the shoulder down on to the 

* Thouverey, ThZse inaug., Paris, 1827, No. 243. 

t Nieod, An mi aire M6dico-Chir. des Hopitaux, 1819, p. 498. 



376 A TREATISE ON FRACTURES. 

arm, and thus pulling downward on the outer end of the bone, bent 
and broke it at about the middle. 

Lastly, a cause perhaps rarer than any other is muscular action. 
In the Gazette des Hdpitaux,* an account has been given of a young 
and robust woman, who had never had syphilis or taken mercury, 
and who drawing her husband toward her while in bed, broke the 
right clavicle. I have myself seen recently, and as it were one after 
another, two cases of the same kind. November 8, 1844, there en- 
tered my wards a laborer, aged 41, who in heaving some building- 
stones upward had felt a sudden pain and crackling, and was found 
to have a fracture a little outside of the middle of the right clavicle. 
Fifteen days later there came in a young man of eighteen, who hav- 
ing raised a heavy shovelful of rubbish, and making a great effort to 
throw it into his cart, heard a crack in his shoulder, and dropped his 
shovel; he had broken the right clavicle in its inner third. I would 
observe that in both these cases the fragments remained connected, 
and made an angle salient anteriorly. 

Fracture of the body of the clavicle presents notable varieties, 
which are not without relation to its different causes. Thus falls on 
the shoulder most commonly produce oblique fractures in adults, and 
serrated in children; direct blows give rise to serrated, splintered, 
or multiple fractures. 

Lastly, in young subjects, incomplete fractures have sometimes 
been observed. Johnson has quoted two such cases. The one which 
I saw, which was mentioned above, occurred in a young man of fif- 
teen, healthy and of good constitution; the fragments formed an 
angle directly upward, and in view of the patient's age I at first 
thought I had to deal with a complete fracture. But the impossi- 
bility of correcting the angle, even with considerable pressure, soon 
made me change my mind; and bearing down on it still more forci- 
bly, I heard a dry crack announcing the completion of the rupture; 
at the same time the angle yielded and disappeared beneath my fin- 
gers. An analogous case may be found in Dupuytren's Legons. A 
boy of fifteen fell on the outer and anterior part of the right 
shoulder; there was soon severe pain, and impossibility, from the 
pain, of moving the arm; Dupuytren found the clavicle curved for- 
ward. On the third day, Pelletan sought to remedy the curvature 
by pressing upon it ; at the first attempt a cracking was heard by 
many of the students, and the fracture was then recognised. f Not- 
withstanding Dupuytren's opinion, I should see in this case all the 
characters of fracture not at first complete, but made so by the 
surgeon. 

But complete serrated fracture, the fragments remaining in contact, 
is much more common, especially in children, and should not be 

* October 5, 1844. f Dupuytren, Legons Orales, tome i, p. 115. 



A TREATISE OX FRACTURES. 377 

confounded with the preceding form; I have already said that Sanson 
(See p. 66) committed this error. Sometimes then the fragments 
are bent at an angle; again there maybe no displacement; Monteg- 
gia saw some of these fractures which were undetected until their 
cure was in progress ; he even saw some in which consolidation was 
complete, the callus alone betraying their existence. The same thing 
may occur in adults: Brunninghausen relates the case of a joiner, 
who got a fall, striking the clavicle against a post. There was much 
contusion, but no displacement or crepitation ; and Brunninghausen 
and Siebold discovered no sign of fracture. The man went back to 
his work : but three days afterwards he returned, his pain having in- 
creased, and this time the injury was recognised.* Amesbury saw 
such a fracture treated as a mere contusion. 

Serrated fractures may however be attended by the most marked 
displacement ; generally then one or more of the serrations are 
broken off, constituting so many splinters. 

Oblique fractures vary in the first place according to the degree of 
obliquity. Fig. 17 presents a very considerable obliquity, slight 
however if we believe Ravaton's statement, that he saw a fracture 
extending nearly two inches along the bone. But it is the direction of 
the obliquity which is chiefly important, by necessitating, so to speak, 
the direction of the displacement. Generally the line is from with- 
out inward and from before backward ; sometimes inward and 
forward: sometimes, but rarely, in exactly opposite directions. 

Multiple fractures differ as to their number as well as their seat, 
in each case. Fig. 20 shows one fracture at the acromial, and 
another at the sternal end of the same clavicle ; in such a case each 
one would be like a single fracture. But if two or three occur 
together in the body of the bone, the middle fragment, very short 
and almost completely detached from the soft parts, sometimes turns 
round among the rest ; a sort of displacement impossible to overcome. 
I have seen in a little girl a double fracture in which the middle 
fragment, about two centimetres in length, was situated vertically 
between the two others ; all my attempts to disengage it were futile. 
M. Guersant, to whom I sent it at the Hopital des Enfants, was not 
more fortunate ; callus was deposited, but with notable deformity. 

In fracture with overlapping, which is most commonly the case, 
the symptoms are numerous and characteristic. At the instant of 
its occurrence, the patient feels severe local pain, and sometimes 
hears a crack as the bone gives way; almost instantly the movements 
of the arm and shoulder become either impossible or very difficult, 
on account of the pain ; the shoulder, dragged by the weight of the 

* Brunning-hausen, De la fracture dela clavtcule ; Biblioth. Germanique, 
tome ii, p. 403. 



378 A TREATISE ON FRACTURES. 

arm, falls downward, inward and forward ; the forearm hangs in a 
state of marked pronation; to avoid at once the stretching of the 
cervical muscles and the pricking of the tissues by the points of the 
fragments, the patient inclines the head and body toward the fracture, 
turning the face a little the other way; and sometimes he carefully 
supports the forearm with the other hand. The clavicular region 
being exposed, we see the point of the shoulder lowered, carried in 
toward the sternum, and more prominent forward than usual; with 
the finger, and very often with the eye, the depression of the outer 
fragment, and the prominence and overlapping of the inner, may be 
recognised. The two fragments can be moved one on the other ; 
they can be replaced by carrying the shoulder upward, outward and 
backward ; and all these movements give rise to a more or less 
marked crepitus. 

Among these symptoms there are two which demand special at- 
tention ; the difficulty of movement, and the displacement. 

"The patient," says Boyer, " cannot raise the arm and carry it 
forward; he is particularly incapable of the movement of circumduc- 
tion by which the hand is carried to the front of the head or to the 
shoulder of the opposite side ; and if directed to put his hand to his 
head, he executes the movement partly by flexing the forearm, 
partly by inclining the trunk and head toward the wrist." This 
description is far from being always exact. " Every one knows," 
says M. Gerdy, "that the arm can be easily carried forward and 
backward; it is therefore only forced abduction and elevation, such 
as take place when the hand is put to the head, which are hindered." 
Bichat explained the loss of these movements by the very feet of the 
rupture of the bone, putting the patient, so to speak, among the non- 
claviculated animals. M. Gerdy has disposed of this theory ; and it 
suffices at once to consider that cats, although destitute of clavicles, 
pass their paws over their heads with great ease. But the study of 
this phenomenon in man plainly shows the chief cause, as pointed 
out by Brasdor, to be nothing more or less than the pain. This is 
so true, that a patient who at first moved the arm only with great dif- 
ficulty, can raise the hand to the top of the head with ease as soon 
as the pain subsides; and that if the fracture is transverse, the 
movements are almost completely restored before the occurrence of 
consolidation. Moreover, it is not rare to see patients able from the 
very first day to carry the hand to the head, when the fracture is 
attended with but slight pain.* The most striking case of this kind 
is certainly that observed by M. Ferrus in 1831 ; it was in an insane 
man whose sensibility was almost entirely destroyed. He fractured 
his clavicle, and the fragments were considerably displaced ; and yet 

* Gerdy, Obs. et Rtflex. sur les fract. de la clavicule, etc. ; Archives de 
Me'decine, 1834, tome vi, p. 356. 



A TREATISE ON FRACTURES. 379 

he raised the arm and moved it in all directions with apparently as 
much facility as he did that of the other side.* 

For the rest, the pain alone does not seem to me to explain the 
hindrance of certain movements, and the amount of overlapping has 
probably something to do with it also. I should say indeed on this 
point that Bichat's theory is not to be absolutely rejected ; and that 
a broken clavicle, with marked displacement, actually does assimi- 
late the patient to the non-claviculated animals. These latter can 
carry the paw to the head, but cannot carry it thence outward, and 
especially backward; likewise in our patients, the elevation of the 
arm backward and outward, and movement of the hand backward are 
impossible except within certain limits. 

The displacement varies with the direction of the fracture. The 
most frequent is undoubtedly that in which the outer fragment is 
drawn downward; and this comprises three varieties. Sometimes 
the fragment descends equally in its whole extent, and in a plane 
parallel to the sternal fragment; Fig. 19 will illustrate this. Some- 
times the fragment, although carried entirely below the other, is 
more depressed at its acromial end; this may be clearly seen in Fig. 
21, taken from a specimen in the Musee Dupuytren. Lastly, when 
the fragments are still connected, the outer one quite often inclines 
downward by its acromial end, making with the inner one an angle 
salient upward; Delpech gives a case of this kind; I have myself 
cited one in my Anatomie Chirurgicale, and have since met with 
another. 

There are some fractures in which the outer fragment remains on 
a plane above that of the other. This curious variety was pointed 
out by Hippocrates; Desault has published an instance of it, and 
the first broken clavicle I had occasion to treat was of just this kind. 
The case is very rare ; most of the classical writers have passed it 
over in silence, and I have myself never seen any case but the one 
alluded to. 

Overlapping comes second in the order of frequency. It is want- 
ing in the majority of serrated fractures, especially in young subjects, 
and varies extremely in degree. Sometimes it is limited to a few 
millimetres; but in Fig. 19 it was more than two centimetres; and 
in the Musee Dupuytren there is a clavicle (No. 60) which has lost 
nearly one-third of its length by overlapping. 

In the third form of displacement the outer fragment is generally 
carried more or less back from the inner, while its acromial ex- 
tremity is on the contrary carried forward. In Figs. 19 and 21, the 
inner fragment projects considerably forward, from the outer one 
retiring backward; and so also in Fig. 17, where the obliquity in- 
ward and backward makes such a result as it were necessary. It is 

* Gazette des Hopitaux, Jan. 18. 1831. 



380 A TREATISE ON FRACTURES. 

in such cases especially that the shoulder is carried forward ; and the 
two fragments form an angle salient posteriorly. 

If on the contrary the fracture is oblique inward and forward, the 
outer fragment almost necessarily rests in front of the other. Of this 
an example is seen in Fig. 20; the shoulder cannot then be carried 
forward but with great difficulty ; the two fragments overlap without 
forming any angle, or perhaps this angle may be salient forward, as 
seen in the figure. Sometimes also in serrated fractures the frag- 
ments remaining in contact make a very marked angle in front, of 
which I have before quoted two instances. 

Finally, M. Grout was the first to point out a fourth form of dis- 
placement, in virtue of which the upper face of the acromial frag- 
ment looks forward, its posterior edge being upward ; the specimens 
represented in Figs. 18 and 21 offer this kind of partial rotation.* 
But it would seem to be entirely artificial, and due to an excessive 
elevation of the shoulder in the course of the treatment. 

All these displacements are generally described as if they con- 
cerned only the external fragment ; it must however be borne in 
mind that the inner one is also movable; that in virtue of the dif- 
ferent obliquity of the fracture, and of the overlapping, it is itself 
pushed in the opposite direction from the outer one ; that the action 
of part of the sterno-cleido mastoid muscle tends to draw it upward, 
and sometimes holds it with extraordinary force. 

This is not all ; even when it is put in proper relation to the other 
fragment, it is liable to be again displaced by the least movement of 
the head, of the trunk, or even of the opposite arm. M. Guerin (de 
Vannes) has particularly called attention to this mobility of the 
inner fragment ; he has proved it both in the living and dead sub- 
ject ; when the fracture was most perfectly reduced, it sufficed for 
the patient to turn his head or move the arm on the sound side to 
derange the fragments and even produce very distinct crepitus. f 

The course of these fractures is generally very simple ; the clavicle 
is a spongy bone, and unites with great rapidity. Hippocrates has 
fixed the duration of the treatment at fourteen to twenty days, and 
consolidation has indeed been occasionally seen at the end of this 
time. But these are exceptions upon which it would be folly to base 
any calculations, except in children, and in fractures without any 
displacement whatever. Avicenna laid down as the general rule a 

* It may perhaps be conceived, by considering on the one hand the normal 
curvatures of the clavicle, and on the other hand the displacements, so very com- 
plex, to which its fragments are subjected, how difficult it is to represent them with 
the pencil. I have had other drawings made than those from Fig. 13 to Fig. 20, 
inclusive ; these have been as many as three times re-attempted under different 
aspects ; and yet they are far from giving an exact idea of the specimens which 
I had before me. 

f Archives G6n. de Me'decine, May, 1845. 



A TREATISE ON FRACTURES. 381 

term of thirty days ; and when the fracture is very oblique or the 
displacement very marked, according to the experience of Delpech 
the apparatus should be kept on until the sixtieth day, or even 
later. 

In some cases the fragments do not become united, especially if 
they have been widely separated, but sometimes also when they have 
been kept in contact ; of tins a curious instance is shown in Fig. 18. 
It is to be regretted that we have no information as to the origin of 
this specimen, which was given to the Muse'e Dupuytren by Laennec. 
It can only be affirmed that the fracture was of ancient date. On 
examining it with care, we see that the sternal fragment is carried 
upward and forward, and the acromial upward and backward, with 
very marked overlapping. The fragments are connected in this 
position by a false joint, and it would seem that the shoulder, thus 
badly supported, has drawn the acromial fragment strongly down- 
ward, so as to make it form with the other an angle salient upward 
and forward; then by the effect of time and of the pressure of the 
integuments, not only has this angle been rounded off, but the sternal 
fragment has actually bent so as to assume an unnatural curve, so 
that it would be in vain to rectify the relative position of the frag- 
ments; the natural form of the bone could never be restored. The 
specimen has been sketched with the angle downward which naturally 
is upward, in order clearly to display this curious secondary curve. 

It may be said in this case, that a true diarthrosis was formed; 
another instance is reported by M. A. Petit.* It is much more 
common to see the fragments entirely isolated, free as it were among 
the tissues. Conditions so diverse involve consequences no less vari- 
able. M. Gerdy has related the case of an old cuirassier, who had 
an ununited fracture of the right clavicle ; at each movement of any 
extent, a crackling was heard, showing that the two fragments rub- 
bed upon one another ; the patient, however, who was enrolled among 
the gendarmerie, fulfilled his duties without difficulty. M. Velpeau 
saw equally free motion in the case of a market porter. f But it is 
otherwise when the broken ends are free. Brasdor saw a man who 
had been unable to endure the bandage, and whose fracture was un- 
united. " He could raise his hand to his head and take off his hat. 
To do this, he first carried the arm backward; then he raised the 
hand as high as his head, and brought it over by a movement of cir- 
cumduction." We see that these were not natural motions; but this 
is not all; "it was observed," says Brasdor, "that he was uncertain 
in these movements, executing them unequally and feebly." I shall 
relate a still more striking instance when on the subject of fractures 
of both clavicles at once. 

* M. A. Petit, Coll. d' Observations Gliniques, p. 297. 
f Gorre, These inaug., Paris, 1835, No. 218. 



382 A TREATISE ON FRACTURES. 

I say nothing of the complications enumerated by some writers, 
which consist mainly in lesions of the subjacent vessels and nerves; 
in spite of the proximity of these, I do not know that they have 
ever been injured when the clavicle has been broken. 

The diagnosis is generally very easy. Bichat states that he seve- 
ral times heard Desault establish his diagnosis merely upon the atti- 
tude of the patient on entering the amphitheatre. This would be 
presumptive evidence, but nothing more, since other lesions of the 
shoulder may give rise to the same. The difficulty of carrying the 
hand to the head is no more significant ; but displacement and cre- 
pitation place the matter beyond doubt. 

Crepitus is often wanting in serrated fractures ; we must then look 
for the angle formed by the two fragments. If they retain their 
normal direction, but if the violence sustained, the pain at one point 
in the bone, and the local swelling, induce us to suspect fracture, we 
may first try to bend the bone by pressing upon the probable seat of 
injury with the thumbs ; or, by moving the shoulder in various di- 
rections, Ave may seek to cause angular deformity. This, however, 
must only be resorted to in very recent fractures ; and sometimes, 
however recent the fracture may be, the diagnosis is singularly 
doubtful. 

A young man of twenty-two fell from a horse, striking the acro- 
mion ; a little while after, he felt a swelling at the middle of the 
clavicle on that side, attended with considerable pain. A surgeon 
pronounced it an undetected fracture, united with deformity; but 
J. L. Petit recognised in it a venereal exostosis, and treated it suc- 
cessfully with mercurial frictions. My own opinion is that J. L. 
Petit's diagnosis was based upon unsound reasoning, and the success 
of the treatment does not appear to me to be a positive demonstra- 
tion of its correctness. Duverney relates the case of a child of ten 
or twelve, who had a fracture of the clavicle undetected for nearly 
fifteen days, and in whom there was commenced a very large and 
deformed callus. Cataplasms, mercurial frictions, and a plaster con- 
taining mercury, were used; in fifteen days extension and counter- 
extension were made without pain, and the child recovered very well. 
The use of the frictions proves nothing in this case; it does not prove 
much more in the other. I dwell upon these facts in order that 
practitioners, when in similar difficulties, may maintain a prudent 
reserve ; I shall relate elsewhere, in connection with fractures at the 
sternal end of the bone, the history of another obscure case, the 
nature of which was only detected after some days. 

The prognosis, considering the trifling severity of this fracture, is 
quite unfavorable. Slight as the displacement may be, the surgeon 
cannot promise union without deformity; the announcement from 
time to time of complete successes is due generally to the credulous 
exaggeration of the relators. The deformity diminishes in time, as 



A TREATISE ON FRACTURES. 383 

the osseous prominences are absorbed ; Fig. 18 shows what may be 
hoped for in this way. When the overlapping is slight, the bone 
retains all its functions ; indeed, it is generally stated that even ex- 
tensive overlapping does not interfere with the motions of the arm. 
Although this opinion dates back as far as Hippocrates, it is none 
the less an error. I have already said that shortening of the clavicle 
notably impedes the backward movement of the arm, and so much 
the more, the more the shoulder is carried forward. 

The treatment has greatly varied, not only as to the means of re- 
tention, but also as to the mode of reduction. 

Hippocrates performed reduction in two ways ; either, carrying 
the hand of the injured side over to the sound shoulder, and thus 
bringing the elbow forward, he pushed the latter forcibly so as to 
make the shoulder as pointed as possible, or he made the patient lie 
down on his back, with something thick between the scapulae; now, 
an assistant raising the extended arm up over the ribs, the surgeon 
grasped the head of the humerus and pushed it outward with one 
hand, while with the other he made coaptation of the fragments. 

Paulus iEgineta modified this last plan ; the patient lying on his 
back, with a cushion between his shoulders, an assistant was directed 
to push the shoulders backward while the surgeon made the coapta- 
tion. He gives likewise two other methods : in the first, one assist- 
ant grasped with his hands the arm of the injured side, drawing it 
upward and outward, while another made counter-extension upon the 
sound arm, or still better, upon the neck of the patient. If the ex- 
tension thus made was not powerful enough, a pad of linen or of 
cloth, of sufficient thickness, was placed in the axilla, and the elbow 
brought toward the body. 

Another method which has been much in vogue in modern times, 
is described by Guy de Chauliac as devised by his teacher at Bologna. 
It consists in applying the knee between the shoulders to push the 
trunk forward, while with the hands the shoulders are pulled 
backward. 

A. Pare', while using these plans of the ancients, added to them a 
peculiar precaution : he had the elbow carried backward, the hand 
of the injured side being placed upon the hip. 

ML Grout has advised a still stranger posture, viz., to flex the 
forearm upon the arm to a right angle, and to bring it behind the 
trunk, in the lumbar region ; approximating the elbow to the back, 
and raising it more or less, as may be necessary. 

Lastly, I have sometimes tried pulling upon the arm carried out 
from the trunk, and even raised up at more than a right angle with 
it, when other modes of traction have failed. 

Such a multiplicity of methods accords but badly with Boyer's 
statement that there is no fracture easier of reduction. The truth 
is, that in the majority of cases one easily succeeds in putting the 



884 A TREATISE ON FRACTURES. 

fragments in contact, whatever plan he may adopt ; and that in 
other cases one plan may succeed where another fails, although I 
cannot at present offer any reason for this. Thus, in a child of ten 
years, who had at the same time a very severe wound of the head 
and a serrated fracture at the inner third of the clavicle, and who 
died on the same day, I found that the position necessary to obtain 
perfect coaptation was with the elbow carried upward and forward ; 
while by carrying the elbow directly upward, and the shoulder out- 
ward by means of an axillary pad, the fragments were made to pro- 
ject forward. 

Lastly, some cases are absolutely intractable by any method, and 
this not only when there are splinters, or various and extensive dis- 
placements, but where we have serrated fracture, apparently ex- 
tremely simple, and with no displacement except upward or forward. 
In these latter cases, the only means by which I have succeeded in 
effacing this angle is strong direct pressure ; but as soon as the pres- 
sure is removed, the angle appears as before. 

On the whole, then, not being able to recommend any one as pre- 
ferable to the rest, I would advise the surgeon, in difficult cases, to 
try all these plans for reduction one after the other ; and we should 
be careful not to neglect, as is too generally done, direct attempts at 
coaptation. 

Retention is still more difficult, and the apparatuses for it have 
been multiplied ad nauseam. Moreover, as there are only certain 
indications to be met, there are only certain means to meet them ; 
and many of the apparatuses consist only of new combinations of 
means already known and employed, the special description of which 
would be unnecessary. It has seemed to me preferable to examine 
separately each indication, with the means of fulfilling it. 

I establish here five leading indications. Three concern the outer 
fragment, which should be carried uptvard, hackward and outward; 
the fourth concerns the inner fragment, which should be kept at the 
level of the other ; and the last is to render both fragments immo- 
vable. 

First Indication ; to carry the outer Fragment upward. — The 
method which is at once the simplest and the most used, is to raise 
the arm by means of an ordinary sling, embracing the forearm and 
elbow, and suspended around the neck at the proper height ; but as, 
in order to reduction, the position of the elbow sometimes has to be 
varied, so also must the position for its maintenance be varied; and 
the retaining apparatuses differ according as the elbow is to be 
kept applied at the side of the trunk, or forward, or backward, or 
outward. 

To raise the elbow, keeping it close to the trunk, Hippocrates used 
the ordinary sling ; or, if the patient would consent to stay in bed, 
he put a cushion under the elbow, to keep the shoulder raised as 



A TREATISE ON FRACTURES. 385 

much as possible by leaving it to its own weight. M. Flaubert has 
sometimes employed this latter method in the Hotel-Dieu at Lyons.* 

Some of the Greek surgeons substituted for the sling a bandage 
called afronde; it was formed of a roller, which began above at the 
back of the shoulder, descended below the elbow, came up to the 
shoulder on the same side, and went over to the sound axilla, to be 
brought again to the arm on the injured side ;f which is nothing 
more or less than Desault's third roller for fracture of the clavicle. 

Lastlv. Benjamin Bell gives the preference to a leather trough for 
the forearm and elbow, suspended by straps round the neck. 

To raise the elbow when carried forward, it does not appear that 
Hippocrates used anything but the sling ; and it was only toward the 
end of the last century that Flamant devised the first bandage spe- 
cially designed to effect this. It was a small linen bag of triangular 
form, six or eight inches deep, and wide enough to embrace the 
elbow, the forearm being flexed. At the two angles of its opening, 
to wit, in front and behind, were fixed two bands with which to con- 
fine it. One of these bands was carried in front, and the other be- 
hind, to the sound shoulder, where they crossed one another ; thence 
they descended to the outer part of the elbow, where they crossed 
one another again ; and then they surrounded the trunk and arm by 
one or two circular turns. J 

Quite recently, M. Simonin has substituted for Flamant's sac a 
common cotton cap, deep enough to receive at once the elbow, the 
arm up to the axilla, and the forearm down to the wrist. Two broad 
ribands or pieces of bandage, about two feet long, are sewed, one at 
the posterior part of the opening of the sac, corresponding to the 
back of the axilla, and the other at the anterior part, nearly oppo- 
site the first ; in such a way, however, that the cap being applied, 
this band comes behind the hand. This latter band goes up over the 
sound shoulder and down the back, to be knotted with the other one 
between the shoulder-blades, so as to keep the cap and the elbow sus- 
pended at the proper height. The elbow is then carried a little in- 
ward and forward, and fixed in this position by means of a third 
band ; which, being firmly sewed to the inner edge of the cap about 
three fingers'-breadths from its top, passes in front of the chest, un- 
der the sound axilla, and round to the knot made by the other two 
bands, where it is itself fastened. § 

M. Cruveilhier accomplished the same end with a strong cotton 
band thirty or forty inches long, and eight or nine fingers'-breadths 
wide, except at one end, where the width was reduced to five fingers'- 
breadths for the distance of about five or six inches. This band is 

* Couronne, 77ie.se inaug., Paris, 1820, No. 226. 
f Galen, De fascus. 

X Journal CompUmentaire, tome xxxvi, p. 113. 

\ Bulletin de Thtrapeutique, tome xxiii, p. 34. 

25 



386 A TREATISE ON FRACTURES. 

applied by its small extremity over the front of the chest, passing 
down and around the elbow; it passes up again between the elbow 
and chest to the axilla of the sound side, and thence to the nape of 
the neek, where it terminates by a semilunar notch surrounding the 
neck. From the two angles of this notch descend two cords, which 
are knotted to two similar ones from the angles of the other extre- 
mity. Lastly, to prevent the band from slipping where it goes over 
the* elbow, it should be perforated over the olecranon, and if neces- 
sary further fixed by a few stitches.* 

M. Velpeau uses two ordinary bandages, each about from eight to 
twelve yards long. The elbow being carried in front of the xiphoid 
cartilage, the hand laid upon the acromion of the sound side as if to 
grasp the shoulder, the end of the first bandage is applied at the 
sound axilla; thence it goes up back of the injured shoulder, descends 
alon^ the front of the arm, and then goes outward below the elbow, 
to return to the sound axilla ; this being done three or four times, we 
have so many diagonal spirals arranged obliquely to the fractured 
clavicle, to the axis of the chest, and to the middle of the arm. This 
done, the band is carried horizontally over the back, to be brought 
over the flexed arm and forearm, continuing these circular turns un- 
til the hand which rests on the sound shoulder, and the point of the 
one injured, are the only parts left exposed. The bandage is termi- 
nated by two or three more diagonal and one or two horizontal cir- 
cular turns. The second bandage, well imbued with dextrine, is 
applied over the first in exactly the same way. 

M. Mayor has recently spoken very highly of an apparatus con- 
structed of a triangular piece of linen, long enough to amply sur- 
round the thorax. The elbow being carried forward and inward, the 
triangle is applied over it, its base upward and corresponding to the 
level of the lower third of the arm, its point hanging below and in 
front of the elbow. The two ends embrace the chest, and meet at 
the sound side, where they are fastened by pins or stitches. The 
arm and forearm being thus fixed to the side, the point of the tri- 
angle is brought up, passed between the forearm and the chest, and 
drawn strongly upward, with a direction at the same time toward the 
sound shoulder, so that it exactly surrounds the elbow, and holds it 
forward. After this there is sewed to the portion of the triangle 
which is behind the back the middle of another triangle, whose two 
ends pass up over the shoulders like suspenders ; one of these ends 
goes over the sound shoulder, and is fastened to the end of the first 
triangle which was brought up as mentioned ; the other, going over 
the fractured clavicle, descends perpendicularly upon the base of the 
first triangle, and is firmly fastened to it. 

These two positions of the elbow, fixed at the side, or carried in 

* Cruveilhier, Mtdecine pratique 6clair6e par Vanatomie, etc., 1821, p. 187. 



A TREATISE OX FRACTURES. 387 

front of the chest, are those which have principally obtained favor 
among surgeons. A. Pare, as vras mentioned, preferred carrying it 
backward ; and J. L. Petit says that he saw several cases thus 
treated ; the forearm was not otherwise supported than by the ordi- 
nary sling. Dupuytren is the only one I know of, who has tried 
holding the elbow separated from the trunk ; the patient was laid 
upon his back, with the upper extremity semiflexed and placed on a 
pillow.* 

Second Indication ; to carry the outer Fragment backward. — 
Although this indication has been recognised from the earliest times 
in reference to reduction, it was left for A. Pare to carry it out as a 
permanent thing, by an apparatus. This was nothing more or less 
than the bandage in the form of St. Andrew's cross, called subse- 
quently the stelliform bandage, or the figure-of-8 of both shoulders. 
I shall not allude to the modifications of this proposed by J. L. Petit, 
Brasdor, and others, which are justly forgotten. The figure-of-8 
made of straps and buckles, tried in 1790 by Brunninghausen, after 
having made some noise, was given up even by its author. Lastly, 
in modern times, MM. Recamier, Fabre, and Guillon have sought to 
revive it, making it of cloths folded cravatwise ; in order to give it 
more efficiency, they all advise placing beneath the cross at the back 
a thick cushion stuffed with hair, or what is simpler, with bran or 
oat-straw.f 

This dorsal cushion is not itself of so recent invention ; De La 
Motte used it about the end of the seventeenth century. He laid 
his patient on his back, with a small and very soft cushion between 
his shoulders, directing him to attend 'particularly to separating his 
shoulders as much as possible. 

After the figure-of-8 and the cushions, come a host of other much 
more complicated contrivances, which in the order of their dates may 
be arranged under three heads : dorsal splints, corsets, and braces. 

The first attempt at a dorsal splint was the celebrated croix defer, 
wrongly attributed to Heister, but in reality due to Roland Paul 
Arnaud, demonstrator to the schools of surgery [in Paris] during 
the first quarter of the eighteenth century. This was a piece of 
iron somewhat T-shaped, properly padded, the upright of which de- 
scended to the lower portion of the spine, where it was fixed by a 
strap buckled over the abdomen; the branches, three fingers'-breadths 
wide, came above the shoulders, and to their ends two shoulder-pieces, 
half leather and half iron, surrounding the shoulders and axillae, were 
attached. If the shoulders were not thus sufficiently drawn back- 

* La Clinique, May 3, 1827 ; and Lecons Orales, tome i, p. 110. 

f Brunninghausen, loc. cit. ; Recamier, Bulletin de Tl\4rapeutique, tome xxii, 
p. 105 ; Fabre, Journal des Conn. Me'dico-Chir., 1842, pp. 72 and 238 ; Guillon, 
ibid., p. 196. 



388 A TREATISE ON FRACTURES. 

ward, a thick compress was placed between the scapulae, raising up 
the cross and its branches, and thus attaining the desired end.* 

This apparatus would seem to have been neither much employed 
nor much imitated. I find it stated by Sir A. Cooper that in 1814, 
at St. George's Hospital, in London, there was tried a simple splint 
placed transversely across the shoulders, which were attached to it 
by bandages, in order to overcome a luxation of the acromial end of 
the clavicle which resisted all other means. I mention this attempt 
because it embodies the same idea as the iron cross, and because the 
indication intended to be fulfilled by it was the same as in cases of 
fracture. 

Something similar was recommended in 1835 for fracture of the 
clavicle, by Dr. Keckeley, of Charleston, U. S.f It consists of a 
splint twenty-seven inches long, three and a half wide, carefully 
padded in the middle, and placed across the back at the level of 
the shoulders. At each extremity of this is a mortise, through 
which runs a strap, also padded, and fastened by means of a buckle. 
The end corresponding to each side is fixed to the shoulder by the 
strap passing under the axilla, which is guarded by a small cushion 
with eyelets for the strap to go through. 

The corsets have presented much greater variety. The first men- 
tion of them is found in Duverney, who does not name their inventor. 
"Others," says he, "use two shoulder-pieces of leather, joined by a 
strap passing between them, which is tightened as much as may be 
required to hold the two shoulders back; the space between the two 
shoulders being carefully padded with some soft napkins. "J 

The first corset devised by Brasdor was very much modeled upon 
this. It was formed by two circular bands of leather to surround 
the shoulders ; and at the edge of each band, behind, was sewed a 
piece of leather four fingers'-breadths wide by six in length, these 
two pieces being bored with eyelets along their parallel borders so 
that they could be laced together. But the stiffness of this apparatus 
causing excoriation, Brasdor modified it as follows : 

In place of the two circular leather bands, there were shoulder- 
pieces made of double chamois-skin, well stuffed, sewed to the back- 
pieces above, and buckled to them below. The back-pieces were made 
of strong cloth lined with chamois-skin; they also were padded, and 
laced together in the middle. Thus constructed, the corset might gene- 
rally answer ; Brasdor however judged it useful to add leather sleeves, 
sewed to the shoulder-pieces, and lacing up loosely around the upper 
half of the arm. Lastly, this being found by experience to be liable 
to slip up on the neck, one or two straps were added, one end being 

* Leclerc, Chirurgie complete, 1739, p. 328. 
t Amer. Journal of the Med. Sciences, Nov., 1834. 

j From a note by Deschamps, it would seem that Pipelet was the author of 
this first corset. See the Journal General de Mddecine, tome xxi, p. 283. 



A TREATISE ON FRACTURES. 389 

attached to the corset, and the other to the waistband of a pair of 
drawers, worn day and night. 

Brasdor read his Memoir before the Academy in 1761; and at 
the same time or soon after, Legrand of Aries, Jauberthou and others 
proposed apparatuses of the same kind. That of Legrand consisted 
of two leather loops connected behind by iron buttons received iuto 
holes; Jauberthou used fustian for the shoulder-pieces, and con- 
nected them by a buckle.* Ravaton returned to the circular loops, 
but had them made of thin leather, and well padded; he brought 
them together behind by means of two buckles ; but he added like- 
wise two buckles in front, with the double object of keeping the 
loops at the angle of the shoulder, and preventing the apparatus 
from slipping up on tjie neck. 

Evers. a German surgeon, gave in 1787 a description of a some- 
what simpler contrivance, which very nearly approaches to the first 
corset of Brasdor. It was composed of two straps to surround the 
shoulders ; these straps were sewed above, and buckled below to two 
oblong pieces of leather like those of Brasdor, except that instead 
of being laced together they were joined by three buckles. Subse- 
quently, this corset having like all the rest the inconvenience of 
slipping upward, Hofer added a girdle fixed around the pelvis, to 
which the corset was fastened behind by two vertical straps. f Sir 
A. Cooper adopted this apparatus, all except the girdle, which he 
replaced by drawers like those of Brasdor. 

I shall pass over a host of other corsets, more complicated, but 
no better calculated to fulfil the indications. Amesbury, on the 
ground that all the shoulder-pieces in use tended to depress the outer 
fragment, made his six inches wide, so as to embrace the summit of 
the shoulder and the upper part of the arm. This is the only 
peculiarity of his corset, which is otherwise quite complicated, and 
seems to be nothing more than an imitation of Brasdor's leather 
sleeves. 

There remain to be described two contrivances with springs, the 
first of which, due to Brunninghausen, bears the name of the elastic 
lever, and is meant to act like the iron cross and the dorsal splints. 
It consists of a broad, thick, oval pad, arranged with springs so as 
to give it the required elasticity, and placed between the shoulders. 
From its sides pass off two iron branches, on a level with the 
shoulders, which are fastened to them by steel shoulder-pieces. 

The other apparatus, devised by Hubenthal, presents at least a 
somewhat more original idea. From the back part of a girdle buckled 
around the chest, arise two springs curving upward and forward over 
the shoulders, drawing them backward by their mere elasticity. 

* See Brasdor's Memoir, already quoted, 
t See Richter's work and its Atlas. 



390 A TREATISE ON FRACTURES. 

They are fastened by bands to the girdle in front, so as to prevent 
their being disarranged.* 

Third Indication; to carry the outer Fragment outward. — This 
indication really consists in overcoming the overlapping; and there- 
fore in fact in making permanent extension. 

Papini is the only one, if I mistake not, who has attempted to 
employ here the system of distension. f He made use of a splint 
arranged in front of and parallel to the clavicle, its inner end being 
fastened by means of a strap to a girdle buckled around the chest, 
as high as possible ; its outer end abutted against a leather cap fitted 
to the injured shoulder; the rest of the apparatus it is not worth 
while to describe, but this idea merits notice. 

Except in this attempt, the lever-plan has been exclusively em- 
ployed; and always by means of a pad in the axilla, over which the 
humerus plays as over a fulcrum, the elbow being drawn in toward 
the side. 

It has been seen that in order to make reduction, Paulus iEgineta 
put a linen or woollen pad in the axilla ; but this pad is found long 
before his time in the dressing described by Galen under the name 
of Spica of Crlaucias. In the seventeenth century, Fournier recom- 
mended a small cushion or pad, stuffed with linen, wool or hair; 
Duverney contented himself with a thick compress ; Desault devised 
a cushion made with old linen, four or five inches wide, of the length 
of the humerus, but wedge-shaped, its base being about three inches 
thick, and fitting into the axilla. Boyer, finding the linen too hard, 
stuffed his pad with cotton. M. Al. Ricord has since contrived an 
air-cushion made of fine leather, cut and sewed so as to form a cone ; 
within this is put a bladder, blown up from its urethral orifice, one 
part of the base being left open for this, and sewed up when the 
bladder is filled. J This was still of the same shape as Desault's 
pad ; Flamant, in 1808, found the length of the wedge inconvenient, 
and shortened it to one-third or at most one-half tliat of the arm; 
he preferred the pad, which did not compress the muscles of the 
axilla. § Lastly, Sir A. Cooper used oblong cushions, padded so 
softly as to fold around the anterior and posterior walls of the 
axilla. 

The methods of keeping the cushion in place have likewise varied. 
In the Spica of Glaucias, as in Desault's apparatus, which is merely 
a modification of it, the pad or cushion was fixed by turns of a band- 
age. Boyer attached to the upper angles of his pad ribands, which 
passed up to be tied over the sound shoulder; Sir A. Cooper em- 
ployed straps, passing backward and buckled to a corset like that of 
Evers. 

* See for the first of these contrivances Richter's Atlas, and for the second 
that of Behrend. 

t Gazette Medicate, 1835, p. 298. % Revue Midicale, 1826, tome, i, p. 28. 

\ Op. cit. y Journal CompUmentaire, tome xxxvi, p. 113. 



A TREATISE ON FRACTURES. 391 

It remains now to fix the elbow to the trunk. Glaucias and De- 
sault do this bj circular turns of a bandage, passing around the arm 
and the chest. Others have used a body-bandage instead of these ; 
we have mentioned the method of Flamant and Cruveilhier for keep- 
ing the elbow forward. Boyer had a girdle made of cloth and quilted, 
five inches wide, fastened around the chest with three buckles, about 
on a level with the elbow. A cloth bracelet, also quilted, was laced 
around the lower half of the arm, and attached to the girdle by 
means of four straps and buckles, two in front and two behind, so 
that by tightening or loosening the lower pair, the elbow was carried 
more or less forward. This corset has served as a model for several 
others, such as those of Reynaud, Delpech, etc., which it is unneces- 
sary to describe. 

Fourth Indication ; to depress the Sternal Fragment. — This in- 
dication was noted from the origin of our art, and has given rise to 
various plans. Some apply over the projection a number of com- 
presses; others prefer a plate of lead; the whole maintained by 
turns of a bandage, generally the spica of the shoulder. This band- 
age being readily deranged, some would bind the trunk first in a 
girdle, and then attach to this girdle, before and behind, turns of a 
bandage pressing directly on the clavicle. Others, lastly, carry the 
bandage over the clavicle and under the perineum. 

Hippocrates, who describes these plans, says that experience had 
shown him their inefficiency. 

In the time of Celsus, however, this indication had been again 
taken up, and in the case of multiple fracture, a mould was applied 
over the fragments, lined with wax. Albucasis resorted to tow, 
pressed upon by a pad and splint along the clavicle ; and we find 
these contrivances carefully preserved until the eighteenth century. 
It may be added that in our own time M. Mayor has again recom- 
mended cotton soaked in the wmite of egg, and a wire trough, not 
conceiving that he was merely following after the Greeks and 
Arabians. 

Another attempt was made by Hubenthal, consisting in covering 
the fracture with a mould in plaster; and he says that he thus cured 
a fracture of the clavicle in a lady, without deformity.* 

Lastly, recourse has been had to mechanical compression. Brasdor 
relates that he saw a young man in whom the prominence of the 
upper fragment was so great that Yacher, who was treating him, had 
had to use a pad almost like that of a truss; it was fixed upon a 
stem whose other end was fastened in the axilla of the sound side. 
Richter describes an apparatus of Zudnachowski's, in which the pad 
was arranged upon a spring, the other end of which was fixed in 
front of the axillary cushion. An analogous contrivance has been 

* Nouv. Journal de Mfdeczne, tome v, p. 212. 



392 A TREATISE ON FRACTURES. 

employed by M. M<51ier, in which the spring was attached behind a 
vei'v strong" girdle, and came up over the shoulder of the injured 
side. 

Fifth Indication; to keep both Fragments at rest. — There are, 
among the appliances which have been mentioned, some intended to 
maintain the fragments at rest, such as the mechanical compressors; 
but M. Ghie*rin (of Vannes) first conceived of preventing any motion 
of the inner piece, by fixing the head and the sound arm. In order 
to this, he advised that the arm should be held firmly against the 
side, which was easily done by means of a body-bandage, and the 
face turned from the fracture, by a dextrine-bandage covering the 
head and the affected shoulder. 

Such are the principal means devised to fulfil each indication; 
such the elements which, sometimes alone and sometimes combined, 
go to constitute all the apparatuses known. But it will not be with- 
out interest to study now these apparatuses in the order in which 
they have been brought forward, and to find out through what varia- 
tions the practice of the profession has passed. 

Hippocrates concerned himself with only two indications ; to keep 
the shoulder elevated, and to act upon the fragments by means of 
compresses and bandages ; he had however but little confidence in 
the latter. Glaucias and Paulus iEgineta attempted also to carry 
the shoulder outward by means of an axillary cushion ; and these 
three were the only indications recognised and aimed at until the 
time of A. Pare'. 

A. Pare' more particularly endeavored to carry the shoulder back- 
ward, founding in this respect a doctrine which prevailed for more 
than two centuries, and which even now has numerous partisans. 
Among his successors, some employed at once the pad, the sling, the 
figure-of-8, and the bandage above the fracture, thus trying to fulfil 
four indications; others limited themselves to the sling or to the 
figure-of-8, or used simple corsets. 

Desault started another revolution, rejecting all the means in use 
for carrying the shoulder backward, although he had admitted that 
this indication was a constant one; but it is very evident that his 
dressing, copied from those of the ancients, could at most carry the 
shoulder upward and outward. These two were the main indications 
recognised by the school of Desault; thus Boyer, Flamant, and 
M. Cruveilhier carefully preserved the axillary pad; only the two 
latter thought that adducting the elbow in front of the chest would 
carry the shoulder backward ; which it would do if the clavicle were 
sound, but not if it were broken. 

While Desault returned to the views of the ancients, in opposition 
to the school of A. Pare", Sir A. Cooper returned to the views of this 
school in opposition to those of Desault; and he extolled the corset, 
combined with a sort of axillary pad. We have seen also, within a 



A TREATISE ON FRACTURES. 393 

few years, MM. Fabre and Guillon disputing as to the priority of an 
apparatus constructed as follows: (1) a cravat making a figure-of-8 
around the shoulders, with a pad between the two scapulas, to draw 
the shoulders back ; (2) an axillary cushion and a circular cravat 
confining the elbow to the trunk, and carrying the shoulder outward ; 
(3) a sling to carry it upward; thus fulfilling three indications. I 
have mentioned the means hitherto employed to depress the inner 
fragment and insure its contact with the other ; and lastly the ideas 
of M. Guerin (of Vannes) as to preventing any mobility between the 
fragments. It should be added that M. Gue'rin recommends at the 
same time the use of Desault's dressing, starched or dextrinated, to 
satisfy the other indications. 

But while for a century and a half we see the most celebrated sur- 
geons striving to perfect, or perhaps more strictly to complicate, the 
contrivances for treating fractured clavicle, we may follow parallel 
to them another series of no less estimable surgeons, who disbelieving 
in these so-called improvements, return to the simplest means, as did 
Hippocrates before them. Thus De La Motte, Gasparetti, Bruns, 
Flajani, treated these fractures without any apparatus, only by the 
horizontal posture, placing at most a cushion under the back; and 
in our own day Dupuytren and M. Flaubert have followed their ex- 
ample.* Mr. Benjamin Bell merely suspended the arm in a leather 
splint ; Sabatier, Chaussier, and Richerand have at last gone back 
to the simple sling ;f and the apparatuses of MM. Mayor, Velpeau, 
and Simonin fulfil no other indication than that of raising the shoul- 
der by carrying the elbow forward. 

If now we seek to judge of all these contrivances by their results, 
we see that most of them are extolled as producing cures without 
deformity; but we see also that subsequent experience has always 
falsified these promises. It is not that regular consolidation is abso- 
lutely impossible: I have cited cases where there was no displace- 
ment, where union occurred even without any apparatus ; and several 
surgeons have told me that they had cured without deformity frac- 
tures in which at first the fragments were displaced. I therefore 
regard the thing as not impossible, although for my own part I have 
never seen such an instance. But if it be so, why is it that such 
success ifl so rare and so exceptional? Several reasons may be 
given. 

The first, pointed out by Hippocrates, is the intractability of our 
patients, and the impossibility of keeping them entirely at rest during 
the whole of the requisite time. 

The second is the insufficiency of our appliances ; and first it is 
worthy of remark that never yet has any surgeon thought of fulfilling 

* Flajani, Nuovo methodo di medicare alcune malattie, etc., Rome, 1786. 
t Ribes, M&m. et obs. d 'anatomic, etc., tome ii, p. 72 ; Richerand, Hist, des 
progris re'cents de la chirurgie, p. 132. 



304 A TREATISE OX FRACTURES. 

all the five indications we have mentioned.. But this is not all; 
there are few of our means which do not in some way do harm; the 
shoulder-pieces of the figure- of-8 or of the corsets depress the outer 
fragment upon which they bear; the axillary cushion tends to slip 
forward in front of the chest, drawing forward the shoulder which it 
should push outward ; it makes such painful pressure upon the skin, 
as to have sometimes caused excoriations, inflammation, and even 
sloughing. The pressure over the inner fragment tends to cause 
gangrene of the skin covering it ; the bandages and splints applied 
over both fragments serve only to mask and not to prevent displace- 
ments ; lastly, the sling itself, by elevating the shoulder, may cause 
such rotation of the outer fragment as to bring its superior face in 
front. 

A third source of difficulty is in the different kinds of fractures, 
some being irreducible, and hence n.ot to be maintained in exact posi- 
tion; while others are easy to adjust by coaptation with the fingers, 
but instantly become deranged when we attempt to replace the fingers 
by any apparatus. Ravaton relates an instance of oblique fracture 
in which he was obliged to perform reduction several times over, and 
advises that we should repeat it ten or twelve times or more within 
six weeks, seeing that in proportion as the callus becomes firm the 
displacement will be less and less likely to recur. I have treated a 
serrated fracture with displacement angularly upward, which disap- 
peared under pressure with the thumb, only to reappear at once in 
spite of all the positions and appliances of which I could conceive ; 
and it would be easy for me to multiply instances of recurrence quite 
as obstinate. 

Lastly, we have also sometimes to blame the blind routine pur- 
sued by surgeons, who put confidence in one method, and seek to 
apply it invariably in all cases. It is clear however that as we must 
vary our means of obtaining reduction, we must also vary those for 
keeping it up. Hippocrates remarked that some fractures do best 
with the elbow placed at the side, while in others it must be carried 
forward; and Duverney also advises varying the bandage according 
to the fracture. Sometimes an attentive examination may even re- 
veal new and special indications ; thus M. Roche, in a difficult case, 
was -truck with the tendency to projection of the lower angle of the 
scapula, as by a lever-movement; he prevented this projection by 
means of graduated compresses and bandages, and thus succeeded in 
keeping up exact reduction.* Such projection is generally the re- 
sult of the shoulder inclining forward, and is remedied by simply 
drawing it back. Whence arise such differences; whence, for ex- 
ample, this superior advantage of one position over another? I have, 
for my part, many times had proof that it is so; but I cannot give 
any explanation that is at all plausible. 

* Archiv. de Mtdecine, tome xix. p. 59. 



A TREATISE ON FRACTURES. 395 

On the whole, then, if the patient does not demand an exactly 
regular callus, and if the surgeon does not desire more than the usual 
success, he may boldly reject every form of complicated apparatus, 
bandages, cushions, corsets and splints, and merely keep the shoulder 
elevated or carried backward. One or two trials, made by the pa- 
tient himself, will show sufficiently what is best, whether by means 
of an ordinary sling to keep the elbow to the side, or to carry it 
forward by means of M. Mayor's sling, or to draw the shoulders 
backward with a cravat arranged as a figure-of-8. The callus 
will be no more deformed, and the patient will have the double ad- 
vantage of almost entire liberty of movement, and the least possible 
annoyance. It is merely necessary to guard the parts against ex- 
cessive pressure ; in order to this M. Velpeau puts a piece of linen, 
doubled, between the chest and the arm; M. Mayor applies his 
dressing over the shirt or waistcoat ; in very thin persons the inner 
condyle and the point of the olecranon must be guarded with a little 
pad of cotton. With the same view, and also to prevent any loosen- 
ing, I prefer to the sling an apparatus made with suspender-webbing 
and fastened by buckles ; of this I shall give a more extended de- 
scription in speaking of luxations of the clavicle. 

If however great importance is attached to a perfect cure, the 
surest means, in my opinion, is to make the patient lie on his back 
for three weeks, his elbow fastened to his side or in front of his 
chest, his sound arm likewise kept at rest, his head immovably con- 
fined on the pillow, and lastly the fingers of an intelligent assistant 
applied permanently over both fragments ; this was done by M. Mayor 
for a young lady in Berlin. I have thought of dispensing with this 
assistant by surrounding and confining the two fragments by two 
steel hooks, like the forceps of Museux; just as in the case of the 
serrated fracture with an angle upward, I thought of passing in at 
the summit of the angle a double hook, which by means of a strap 
and band could be drawn toward the elbow, thus exerting all the 
necessary pressure; and having this direct and powerful action, we 
might perhaps spare the patients the annoyance of remaining in bed. 
But these ideas need maturity; hitherto they have not been prac- 
tically applied. 

[In the United States, fracture of the clavicle at any point is 
treated mainly either by Velpeau's bandage, by a simple sling, or by 
Fox's apparatus. The latter consists of a collar, a pad and a sling; 
the collar is a stuffed ring to go over the sound shoulder ; the pad is 
put in the axilla of the injured side, and fastened to the ring by 
tapes before and behind; the sling embraces the forearm and lower 
part of the arm, and is also fastened by tapes to the collar. 

Dr. R. J. Levis of Philadelphia invented about two years ago a 
somewhat similar apparatus, consisting of a pad and sling, and bands 
fastened by buckles; it would probably in some cases be more 



396 A TREATISE ON FRACTURES. 

efficient than Fox's, but is somewhat more complicated, and requires 
greater accuracy in its construction. See the Am. Journal of the 
Med. Sciences, January, 1856, p. 100.] 



§ II. — Fractures of the Sternal Extremity. 

These fractures are very rare, and have hardly attracted the at- 
tention of observers. Lonsdale cites one case occurring from a direct 
blow in a child three years old, and presumes that it was a separa- 
tion of the epiphysis. Quite recently the G-azette des Hopitaux, 
giving an account of a patient in M. Blandin's wards, with a fracture 
situated near the inner end of the clavicle, at the point where the 
first rib abuts against this bone, between the costo-clavicular and 
sterno-clavicular ligaments, calls attention to the fact that in these 
cases there is no displacement, both fragments being kept immova- 
ble, the one by the first rib and the other by the sternum.* 

This theory is incorrect ; for the only two specimens in the Muse'e 
Dupuytren present a very considerable displacement, to which I 
shall presently refer again. When the fracture occurs without dis- 
placement, it is simply because of the interlocking of the fragments 
and the integrity of the periosteum. 

These fractures without displacement may give rise to more than 
one error in diagnosis. I received into my wards in 1843 a man 
aged 28, who seven days before, having fallen into the moat at 
Vincennes, had felt a severe pain near the left sterno-clavicular 
articulation. I found there a hard tumor, formed apparently by the 
end of the clavicle being partially luxated forward ; and such was 
my first impression of the case. However, as no manipulation di- 
minished this prominence, I became doubtful, and called in some of 
my colleagues. M. Piedagnel thought it a tumor of ancient date 
and uncertain nature ; M. Maisonneuve, a sanguineous infiltration ; 
M. Berard was inclined to the belief that it was a fracture in pro- 
gress of consolidation ; and this latter diagnosis was confirmed by 
the statement of M. Mayor, my interne, who had seen the patient 
before his admission, and had then detected crepitus. 

When the external violence produces the displacement, what di- 
rection do the fragments take? In a specimen in the Musee Dupuy- 
tren, (Xo. 64,) the outer fragment makes a marked prominence 
downward and forward, and an analogous one may be seen in the 
bone represented in Fig. 20. Is this form of displacement constant? 
I propose this question without answering it, knowing of no other 
examples of this fracture than those which I have mentioned. 

* Gazette des Hopitaux, April 22, 1845. 



A TREATISE ON FRACTURES. 397 



§ III. — Fractures of the Acromial Extremity. 

Less common than those of the body of the bone, but much more 
so than those of the sternal extremity, these fractures were not 
separately studied until the eighteenth century. Duverney first 
pointed them out as not being liable to displacement. Brasdor ex- 
plained this fact by the equal tension of the deltoid and trapezius, 
inserted into the two fragments and keeping them balanced; un- 
happily for this theory, the only observation recorded in Brasdor's 
Memoir was that of a fracture of this kind in which one fragment 
overrode the other. But disregarding this fact, the absence of dis- 
placement has been still considered as constant ; only that, with 
Bichat, it has been ascribed to the resistance of the coraco-clavicular 
ligament, which keeps together the sternal fragment, into which it is 
directly inserted, and the acromial portion, which is joined to the 
scapula, into which the ligament is likewise inserted. Without ab- 
solutely denying the action of this ligament, I think that the con- 
tact or derangement of the fragments depends mainly on the severity 
of the external violence and the integrity of the periosteum ; in some 
of these fractures displacement may occur to as great an extent as 
in any others. 

We say, then, first, that the seat of this fracture may vary from 
the acromial articulation to the inner border of the coraco-clavicular 
ligament, comprising an extent of about five centimetres. The cause 
is always either a direct blow, or a fall on the shoulder or on the ex- 
tended arm. Generally the fracture passes from before backward, 
and divides the bone vertically ; but it may be oblique, and hence 
give rise to different phenomena. 

There is usually no appreciable displacement. There is little pain, 
hardly any impediment to motion, almost never any crepitus ; so that 
often the only sign of the fracture is pain limited to the line of the 
division. There may, however, commonly be felt a notch, a very 
slight separation between the fragments, especially when the arm and 
shoulder are drawn downward. Sometimes the weight of the limb 
suffices to draw down somewhat the outer fragment ; at other times, 
on the contrary, this fragment is a little elevated above the other. 
M. Gueretin observed, in a fracture situated at the level of the 
inner border of the coracoid process, the external fragment forming a 
projection upward of four millimetres.* Probably this was due to a 
certain obliquity of the fracture ; in a specimen in the Musee Dupuy- 
tren,the fracture appears to have been oblique downward and outward, 
and the acromial fragment rides above the other. (See Fig. 20.) 

In such circumstances, with little or no displacement, we can 
hardly see the use of the inventions of some authors for keeping the 

* Presse Midicale, 1837, p. 43. 



308 A TREATISE ON FRACTURES. 

fragments in position. They keep in place sufficiently of themselves, 
and all that is necessary is to support the arm and shoulder with an 
ordinary Bling. 

But there are other cases, hitherto neglected, in which the dis- 
placement is very great; it is then always the inner fragment which 
overrides the outer. Fig. 21, and still more Fig. 1 9, give an idea 
of the nature and extent of these displacements ; I have seen also 
in the living suhject two remarkable instances of them. 

A man aged 41 had sustained a fall, with his two arms forward. 
The right arm struck first, and the result was a fracture of the right 
clavicle, about one centimetre from the acromial end. He took no 
notice of it, and did not even have it seen by a surgeon. I examined 
it seven months and a half after the accident ; the inner fragment 
was elevated nearly three centimetres above the other ; the overlap- 
ping amounted to a centimetre ; the shoulder was depressed, and 
carried forward and inward, so that a tape stretched from its point 
to the jugular fossa, showed three centimetres and a half less on the 
injured side than on the other ; and to this inclination of the shoul- 
der there corresponded posteriorly a notable prominence of the infe- 
rior angle and posterior edge of the scapula. Everything indicated, 
at the first glance, luxation upward of the acromial end of the clavi- 
cle ; and I was only undeceived by making an exact measurement, 
and by the pointed prominence of the inner fragment. The man 
executed all the movements of the arm very well, except those in 
which it was carried backward ; he had generally no pain, except 
about the humeral insertion of the deltoid, but changes of the wea- 
ther caused pains at the seat of the fracture. 

In the other case, almost exactly similar to this, the fracture had 
been caused by a fall backward on the pavement; it had been treated 
with an apparatus fixing the hand on the sound shoulder, and the 
prominence had been only slightly corrected. 

Fractures of this kind call, therefore, for attention in respect both 
to diagnosis and to treatment. Their symptoms are so similar to 
those of upward luxation of the acromial end of the bone, that the 
comparative measurement of the two clavicles is sometimes the only 
means of avoiding error; and it would appear also that in some cases 
the projecting fragment requires direct and permanent pressure to 
replace it, just as does the clavicle in certain luxa/tions. I say this 
only from analogy, having had no opportunity of seeing these frac- 
tures when recent. 



§ IV. — Fractures of both Clavicles. 

Fracture of both clavicles at once is extremely rare, having oc- 
curred but once among the 2358 cases at the Hotel-Dieu ; for my 



A TREATISE ON FRACTURES. 399 

own part, I have seen it but once, and have been able to collect but 
four other instances. 

The first question is, How can such an accident occur ? Now by 
a singular chance, the small number of cases known gives us in- 
stances of almost every imaginable cause. Thus there was in 1831, 
in M. Yelpeau's wards at La Pitie', a man aged 35, who had old frac- 
tures of both clavicles, which, according to his account, were conge- 
nital. In an old soldier whose history is given by M. Gerdy, the 
two fractures resulted from blows with the butt-end of a musket, — a 
direct cause. M. Reynaud saw a man who had first the right clavi- 
cle broken by a falling piece of wood, and being knocked down by the 
blow, broke the other by counter-stroke; here was a combination of 
direct and indirect force. In the patient at the Hotel-Dieu, the case 
was reversed; he fell first on the left shoulder, breaking that clavicle 
by counter-stroke, and then a carriage-wheel passed over him, and 
broke the bone on the right side. In another case, reported by 
M. Carriere, both fractures were indirect; the patient falling and 
finding himself wedged between two pieces of stone pressing the 
shoulders transversely.* My patient could give no account of the 
mode of occurrence of his accident; he had been thrown by a jealous 
husband from a window fifteen feet high, and did not remember any 
of the circumstances of his fall. It may be remarked that all the 
patients were men. 

The symptoms do not differ from those of one clavicle alone ; 
M. Carriere has noted that in his case the head was kept straight, 
without any inclination to either side. 

But the chief difference lies in the consequences, and in the diffi- 
culty of treatment. Of the six cases mentioned above, non-union 
ensued in three. This result is less alarming when we recall that 
the two cases seen by M. Velpeau and M. Gerdy had not been sub- 
mitted to any treatment; but mine, a young man of eighteen, had 
had applied a corset like that of Brasdor, and a pad in each axilla. 

It is curious to examine the mode in which the functions of the 
arms were performed with this permanent fracture of both clavicles. 
The patient at La Pitie', with an overlapping of more than an inch 
on each side, and extreme mobility of the fragments, still enjoyed, it 
i.s said, all the movements of the arms. There is certainly some ex- 
aggeration here ; and a close examination of my own patient did not 
give me anything like such a result. 

I have stated how he fell, and' how he was treated. Before his 
double fracture he had been a tinsmith; but he could not resume this 
occupation, and became a tailor. Three years afterwards, by a curi- 

* See Gazette des Hopitaux, Dec. 29, 1831 ; Gerdy, Archives de Me'decine, 
1834, tome iv, p. 3G2 ; Reynaud, Bulletin de la SociU6 d Emulation, 1811, tome 
viii p. 323 ; Gaz. des Hopit., Oct. 13, 1831 ; Carriere, Bulletin de TJie'rapeutique, 
tome xxiii, p. 447. 



400 A TREATISE ON FRACTURES. 

ous fraud, he became a substitute in the 24th regiment of the line; 
but being unable to carry cither knapsack or musket, he was on the 
point of being discharged when I examined him at Val-de- Grace, in 
January, 1831. 

Both clavicles had been broken at the middle; the two inner frag- 
ments were nearly horizontal, and very distinct beneath the skin; 
the outer fragments had also a nearly horizontal direction, but were 
buried behind and below the others, to which they seemed to have no 
adhesions of any kind. The overlapping was considerable. 

When he stood up, the two shoulders seemed lower, as well as 
carried farther forward and inward than in a healthy person. The 
one on the right side was higher, and at the same time closer to the 
sternum than the other. Posteriorly, the scapulae were separated 
from the spinal column by three or four inches, and inclined forward 
and outward ; and on the whole the thorax seemed much contracted 
at its upper part. 

He could draw the shoulders a little back, but not enough to over- 
come their apparent prominence anteriorly. On the other hand, he 
could draw them together forward so that they seemed like wings 
covering the chest, and leaving between them, in front of the sternum, 
only three inches' space. In this movement the scapulae fitted to the 
sides of the trunk, and the back seemed rounded from one side to 
the other, almost like that of a skeleton deprived of the upper ex- 
tremities. The shoulders could be raised also at will, but not to 
any extent, from want of muscular power. 

He could raise both arms to a right angle with the trunk, but no 
higher ; but in this movement the elbow had to be carried either 
forward or outward; to carry it backward was impossible. The 
mechanism of this elevation of the arms was very curious to observe. 
It was first the whole shoulder which was raised, and which at the 
same time was carried forward and inward ; when this motion ceased, 
the deltoid acted and raised the arm ; the scapula remained almost 
immovable, and its inferior angle did not advance two centimetres 
even at the highest elevation of the arm. For the rest, whether the 
arm was raised by voluntary effort or passively, the movement was 
arrested at either side by a painful sensation in the axilla; the pa- 
tient said that he felt a nerve stretched. Moreover, neither the 
shoulder nor the arm of the left side could be brought up as high as 
those of the right. In all these movements of elevation the inner 
fragment of each clavicle was raised so as to make an angle of about 
forty-five degrees with the horizon; the outer one was raised also, 
but never as bigh as the other. 

With such limited movements, it may be seen how the occupation 
of a tinsmith became very laborious to him; nevertheless, his fore- 
arms and hands being unimpaired in their action, he could easily 
do the work of a tailor. Still, when he worked a little more than 



A TREATISE ON FRACTURES. 401 

usual, he felt pain at the attachment of the pectoralis major to the 
inner fragment ; and the same pain came on with any change in the 
weather. This part of the muscle was in fact more drawn upon than 
any other. 

Thus then, as might have been foreseen, unconsolidated fracture 
of both clavicles is much more troublesome than that of one alone, 
and it is very important to ward off such a misfortune. Doubtless 
any intelligent surgeon would know how to modify the usual appli- 
ances to suit such cases ; but it may be useful to state what has 
been done. 

The simplest idea is to confine the patient to his bed. This was 
the plan adopted by Dupuytren, merely placing a pillow between 
each arm and the trunk. M. Reynaud likewise kept his patient in 
bed, but applied also such a host of corsets, braces, straps, cushions 
and slings, that I give up attempting their description. All this 
apparatus would seem moreover to have been of but very little use ; 
and at most it would have been judicious to have added to the pillows 
used by Dupuytren a bandage, to confine the arms and elbows. 

The case given by M. Carriere is more interesting, inasmuch as 
his patient was intractable, refusing to keep his bed even for a few 
days. The surgeon then tried a double apparatus, composed of two 
axillary pads, a large girth to act as a body-bandage, and lastly two 
slings to support the forearms and elbows. The patient could not 
endure this confinement of his hands, and sought every opportunity 
of disengaging them ; then M. Carriere took another course ; he dis- 
pensed with the pads and girth, and applied on the left side, where 
the displacement was most marked, the apparatus of M. Simonin ; 
supporting the right arm merely by a sling forming a pouch for the 
elbow, so as to carry it upward and inward. Consolidation was 
complete by the twentieth day, and the man went to his work two 
davs afterwards. 



26 



CHAPTER X. 

FRACTURES OF THE SCAPULA. 

Fractures of the scapula are so rare that Ravaton, after a 
practice of fifty years, declared that he had never seen any except 
those caused by gunshot on the field of battle. Among the 2358 
cases at the Hotel-Dieu there were only four. It may however be 
added that of 1901 fractures treated at the Middlesex Hospital, 
Lonsdale found eighteen of the scapula. Four principal varieties of 
them are recognised, according as they involye the body of the bone, 
the acromion, the coracoid apophysis, or the glenoid cavity ; but as 
the latter are generally accompanied by displacements of the head 
of the humerus, their history may be better placed with that of 
those luxations. 

[When resident in the Pennsylvania Hospital, I had in charge a 
little girl aged two and a half years, who had the neck of the sca- 
pula broken off, with mobility and crepitus ; the head of the humerus 
was undisturbed. The injury was sustained by falling down three 
stairs. The elbow was supported, and the "usefulness of the arm 
completely restored by the eleventh day.] 

§ I. — Fractures of the Body of the Scapula. 

Attempts have been made to distinguish numerous varieties of 
these fractures. In the first place J. L. Petit arranged them into 
transverse, oblique and longitudinal. Subsequently, Desault made 
a special variety of fractures of the lower angle; Boettcher, of those 
of the posterior angle; A. L. Richter brought forward again, follow- 
ing Paulus iEgineta and A. Pare', fractures of the spine of the bone. 
I know of no instance of fracture limited to the spine or to the pos- 
terior angle, nor of any of vertical fracture ; fracture of the lower 
angle does not call for special mention ; and finally, the varieties 
which it is really important to recognise are incomplete, complete, 
whether transverse or oblique, and multiple or comminuted fractures. 

They are generally the result of direct violence, such as a blow, the 
fall of a heavy body upon the scapula, or the falling backward of the 
(402) 



A TREATISE ON FRACTURES. 403 

patient himself. Dr. Heylen has however recently published a case 
attributed to muscular action. A man aged 49, trying to climb into 
his cart, had caught hold of its edge with his left hand, and was 
thus suspended when his horse suddenly started off on a full trot. 
The man was thus dragged, hanging by his left hand, a distance of 
one hundred yards, until the horse stopped. He had severe pain in 
the left shoulder, increased by the least movement; the finger felt a 
depression at the middle of the spine of the scapula, and on pressing 
strongly upon the projecting portion, it gave way with crepitation. 
For the rest, there was no trace of ecchymosis externally, and the 
patient, who had not lost his presence of mind, affirmed that nothing 
had touched the shoulder.* Perhaps the cause here was the weight 
of the body, increased by the jerks from the jolting of the cart, and 
breaking the bone by a sort of traction; but however it may be 
explained, the case is still very remarkable. 

I have seen but one case of incomplete fracture, and know of no 
other example. A laborer being at work in an excavation, with his 
back bent, a mass of building-stone weighing about twenty pounds 
fell from a height of four or five yards upon the left scapula. On 
examination I found a severe contusion at about the centre of the 
fossa infra-spinata ; the finger, when pressed upon this, sunk into a 
very marked depression, limited within by a sharp bony prominence, 
and toward the outer edge gradually coming up to the level of the 
rest of the bone. The scapula moved en masse, and without crepita- 
tion. There was therefore a depressed fracture in the fossa infra- 
spinata. It may be plainly seen that in such a case art would have 
little to do; I merely fastened the arm to the side, so as to keep the 
scapula at rest until the pain subsided. 

Complete fractures, whether transverse or oblique, are seated most 
frequently above the spine. They are sometimes unattended with 
displacement. M. Huguier told me he had treated a case of this 
kind, which he recognised by crepitation and slight mobility. Kirk- 
bride has published the case of a man who was struck by a locomo- 
tive engine and thrown down, striking the rail; he had a transverse 
fracture about two inches below the spine; the fragments could be 
easily displaced, but resumed their normal relation when left to them- 
selves. The patient dying on the fifty-fourth day, the fracture was 
found firmly united, and the callus extending across the bone.f 

But most commonly there is more or less displacement, the result 
at once of the external violence and of muscular action. Fig. 24 
represents the left scapula of a young epileptic, who long before his 
death had had this bone broken by a fall upon his back. There are 
two fractures, nearly transverse; in the first, situated below the 

* See my Journal de Chirurgie, tome iii, p. 151. 

f American Journal of the Med. Sciences, Aug., 1835, p. 307. 



404 A TREATISE ON FRACTURES. 

spine, the lower fragment presents a triple displacement, first for- 
ward, then by overlapping, and then outward. The second, situated 
near the inferior angle, offers nearly the same displacement, but a 
little more marked; and the overlapping in both together is such 
that the bone has lost fifteen millimetres [half an inch] in its length. 

I have seen a somewhat different displacement in a man seventy-one 
years old. who was thrown down by a cabriolet. A fracture of the 
right scapula was detected, and treated by a simple body-bandage. 
By the thirty-fourth day, consolidation seemed to be complete; I 
examined carefully into the state of things; the fracture ran across 
the outer half of the fossa infra-spinata, and then passed up some- 
what obliquely inward toward the edge of the spine. The lower 
fragment was very notably displaced outward ; but so far from being 
driven forward, it made a projection backward; and the finger, 
passing downward along the edge of the scapula, was arrested by the 
very considerable prominence of this fragment, raising up the infra- 
spinatus muscle. Nevertheless, the two fragments were not com- 
pletely separate from one another, for the measurement of the two 
scapulae showed no sign of overlapping. 

Lonsdale relates two cases of simple oblique fracture, but with 
very trifling displacements; the lower fragment being carried forward 
and outward, and the other riding over it. When the fragments are 
disjoined by greater external violence, the displacement assumes a 
new character which would not theoretically be looked for. Figs. 22 
and 23 represent the two aspects of a scapula broken into numerous 
pieces; and one of these fractures divides the fossa infra-spinata 
from below upward and from within outward. Now in place of de- 
scending and overlapping the other, the upper fragment is drawn up 
backward, the lower drawn outward; so that, remaining in contact 
at the neck of the bone, they are separated posteriorly and below 
like the two legs of a pair of compasses. The patient had lived some 
time after the occurrence of the fracture; and consolidation had 
begun at several points, fixing the two principal fragments as is seen 
in the drawings. We may also see plainly that the lowest of the 
fragments, comprising the entire lower angle, is carried in front and 
outside of the middle fragment, over which it also rides, as in Fig. 
24, already described. Probably there had occurred here very ex- 
tensive ruptures of the muscular fibres ; and perhaps such pheno- 
mena are only met with in cases of comminuted fracture. 

The symptoms are generally as follows : local pain, augmented by 
pressure, by coughing or sneezing, or by the movements of the arm ; 
passive motion being much less painful than voluntary. The latter 
was rendered almost impossible, in one of my patients, by the severity 
of the pain. Sometimes the head is averted, as in fractures of the 
clavicle. I noted in one case a considerable ecchymosis, but have 
not met with it in any other. J. L. Petit adds that emphysema is 



A TREATISE ON FRACTURES. 405 

almost always present ; but no one else, so far as I know, has re- 
peated this observation. So far we can but suspect the fracture; 
the really diagnostic signs are crepitation, mobility, and lastly, dis- 
placement. 

It is difficult to produce crepitus by direct rubbing together of the 
fragments, because they afford so little grasp to the hand; we obtain 
it by putting the arm and shoulder through extended motions upward, 
downward, forward and backward, while we keep one hand laid flat 
over the scapula so as better to perceive it. 

Mobility can hardly exist without displacement. In fractures of 
the lower angle, Desault carried the shoulder, and therefore the 
scapula backward, bearing with his fingers on the suspected portion. 
If the angle does not follow the movements of the rest of the bone, 
the fracture is incontestably proved; but even if it does, we cannot 
therefore with Bichat deny the existence of a fracture ; the only con- 
sequence strictly derivable is, that there is no displacement. 

The displacement is not always easily appreciable, especially in a 
fat or muscular patient, and where there is some little tumefaction. 
Any projections along the posterior edge may be well detected by 
making the patient cross his arms over his chest. Another method 
by which I have succeeded is as follows : the forearm is bent up be- 
hind the back, and the hand raised as high as possible; in this posi- 
tion the scapula is separated like a wing from the thorax, and its 
posterior edge, lower angle and external edge push up against the 
skin, and show in relief any abnormal prominences. It is thus also 
that we can best seize hold of the different parts of the bone, and try 
to make them play upon one another so as to cause crepitation. It 
is however well to be careful when we touch the fossa infra-spinata, 
not to be deceived by the edge of the bone outwardly, nor by that 
of the spine within and above, nor by that of the posterior edge near 
the lower angle, within and below. In case of doubt, we should 
examine both scapula in the same position, and carefully compare all 
their prominences. 

With all these precautions, we may perhaps succeed in making out 
the presence of a fracture ; but to say whether it is transverse or 
oblique, single or multiple, is again a difficult matter. Sometimes, 
when there is little or no displacement, crepitation will reveal a frac- 
ture, the seat of which cannot be determined by the touch; but a 
fracture without either displacement or crepitation will be almost in- 
evitably unrecognised. 

It is fortunate that then the mistake is of small importance ; and 
the prognosis is no more serious even in cases with the m'ost marked 
displacement. Mr. Benjamin Bell affirms that they very commonly 
give rise to permanent stiffening of the movements of the arm; but 
for myself I have never seen anything of the kind, and I have not 



406 A TREATISE ON FRACTURES. 

even seen any appreciable hindrance to motion in the cases I have 
observed. 

Fractures without displacement require nothing but rest, and it is 
sufficient to keep the arm fastened to the trunk with a body-bandage 
and a sling. 

When displacement exists, various modes of obtaining reduction 
have been tried. Pierre d'Argelata put a pad in the axilla, and drew 
in the elbow against the ribs. J. L. Petit advises raising the arm 
till the bend of the elbow is opposite the nose, and then that an 
assistant should hold it thus while the surgeon tries to adjust the 
fragments. Bell recommends raising the head and shoulders so as 
to relax the muscles of the back. Heister had the arm drawn for- 
ward ; Desault, in fractures of the inferior angle, carried the arm in 
front of the chest and a little off from it, the hand of the injured side 
being laid upon the sound shoulder. 

Surgeons have not been much more agreed as to the plan of treat- 
ment to be adopted. Paulus iEgineta treated these fractures like 
those of the clavicle, advising that the patient should be kept lying 
on the sound side. Albucasis applied a sort of pad over the bone, 
covered with compresses and with a wooden or leather splint. De- 
sault employed a wedge-shaped cushion, the edge answering to the 
axilla and the base forming a fulcrum against the chest, for the arm ; 
the whole was retained by a bandage seven or eight yards in length, 
the first few turns of which were intended to fasten the hand of the 
injured side upon the sound shoulder. Boyer, disregarding any dis- 
placement, attended only to keeping the bone motionless ; and there- 
fore, by means of suitable bandages, he fastened the arm to the side, 
carrying the elbow somewhat forward. 

Among these different plans, how is the surgeon to make his 
choice ? Are we to perform reduction, and have we any means of 
doing so? 

The three indications to be fulfilled are, to carry the lower frag- 
ment backward and inward, and the upper forward and outward, and 
to correct any overlapping. The lower fragment seems drawn upon 
mainly by the teres major muscle; we must therefore, in order to 
relax this muscle, approximate the arm to the trunk, carrying it at 
the same time somewhat backward. The upper fragment appears to 
be acted on by the rhomboidei, which are relaxed when the shoulder 
is elevated and thrown back. As for overlapping, I know of no 
means of obviating it. 

Mere position will doubtless be insufficient to correct the two for- 
mer displacements; coaptation must be made with the hands, and 
then the permanent apparatus should comprise: (1) some means of 
keeping the shoulder upward and backward, and the elbow close to 
the chest, as in case of fracture of the clavicle; (2) some suitable 
substitute for pressure with the hands; a pad over the upper frag- 



A TREATISE ON FRACTURES. 407 

raent, pushing it forward against the other ; graduated compresses 
internal to it, pushing it outward; and the same external to the lower 
one, pushing it inward. 

This is at least what would seem to be indicated by the actual dis- 
placements and the most probable theory; but here, as in many other 
instances, nature laughs at our speculations; and for my own part, 
in the cases of this kind which I have treated, I have never been 
able to reduce the displacement by any of the means mentioned, 
and still less to keep the fragments in place. I should say, indeed, 
that positions apparently the most rational sometimes increased the 
derangement, which was lessened by others, varying in each case. 
If, there/ore, the surgeon determines to accomplish reduction, the 
only advice which my experience authorises me to give is, to try all 
possible attitudes until he hits upon the best, and then to endeavor 
to maintain it during the whole time requisite for consolidation. 

But in the majority of these fractures all this trouble is unneces- 
sary; reduction, so often impossible to effect, is not of very great 
importance, and I merely keep the arm elevated by means of an 
ordinary sling, fastening it also to the trunk by means of a body- 
bandage. 

§ II. — Fractures of the Acromion. 

These fractures have seemed to me more rare than those of the 
body of the bone ; but among the eighteen cases given in Lonsdale's 
table, we find eight of each. They were mentioned by Denys Four- 
nier, in the seventeenth century ; but Duverney was the first to re- 
port instances of them.* 

They are sometimes produced by direct causes, such as the fall of 
some heavy body upon the top of the shoulder; Bichat has related 
one case,y and Avrard another.^ But more commonly they result 
from falls on the shoulder, in which the acromion, striking the ground 
by its external border, breaks by counter-stroke at some point a lit- 
tle within this, and as by a force tending to bend it away from the 
arm. This mecKanism is quite apparent in Duverney's two cases, and 
in another reported by Lonsdale. I have seen such a case also in a 
man aged 59, who, standing on the second round of a ladder, fell 
backward and struck his shoulder against an anvil. 

The seat of this fracture varies. Sir A. Cooper cites a case in 
which it involved the articulation with the clavicle, and in which the 
clavicle was at the same time luxated; but it generally takes place 
back of this articulation, as may be seen in Fig. 25; an inch or less 

* Chapter De la fracture de la davicule, obs. 1 and 2. 

f M6m. sur la fract. de V acromion ; Oeuvres posthumes of Desault, tome i, 
p 99. 

X See my Journal de Chirurgie, 1845, p. 252. 



408 A TREATISE ON FRACTURES. 

from the point of the acromion, external to its posterior angle, near 
the point of attachment of the epiphysis. It follows a straight line, 
and generally divides the hone vertically; although M. Ndlaton has 
seen a case in which it ran obliquely, the portion next the spine being 
bevelled at the expense of its superior surface.* 

The symptoms also vary greatly. The shoulder displays com- 
monly ecchymosis of greater or less extent, sometimes limited to the 
seat of the injury, sometimes spreading down toward the* axilla, and 
even reaching the lower part of the arm. The swelling is due to 
the external violence. 

The pain is sometimes very severe. In the instance which I ob- 
served, all movement was rendered impossible, so that the man could 
not even take off his coat. In Desault's patient the pain merely 
made motion of the arm difficult, and especially its elevation; it was 
increased by any such movements, and moreover, what is remark- 
able, by turning the head toward the sound side. Lonsdale ob- 
served in his case also the impossibility of raising the arm. But in 
one of M. Nelaton's cases, although the displacement was consider- 
able, the patient, who was seventy-five years old, preserved all the 
movements of the arm, carried it forward, backward and outward, 
said that he felt no pain, and would wear no apparatus. I would 
say, however, that no express mention is made of elevation directly 
outward, which according to Lonsdale was the only impossible move- 
ment. 

The diversity is as great in regard to the displacement. Some- 
times the fragments remain in contact, nothing betraying the frac- 
ture externally ; in a case of this kind, M. Nelaton discovered »upon 
dissection that the periosteum had remained entire beneath, and that 
above it was but partially torn. With a more considerable rupture 
of this latter, the outer fragment would have slanted so as to make 
with the other an angle superiorly; as seems to have occurred in the 
specimen represented in Fig. 25. Had both sides suffered alike, the 
piece might have been more or less drawn down, without making any 
angle with the other ; in the acromial fracture shown in Figs. 22 and 
23, the descent amounted to a millimetre ; but, what is quite curious, 
the fragment was carried also five or six millimetres backward. 
When lastly, the periosteum is ruptured completely both above and 
below, the outer fragment is entirely detached, and very much low- 
ered. Thus in M. Nelaton's old man, just cited, in tracing the spine 
of the scapula an abnormal prominence was felt in front, and then 
a depression in which could be lodged the pulp of the finger. The 
acromion, depressed about half an inch, was entirely movable, and 
independent of the rest of the bone; when the patient carried the 
arm forward, the apophysis followed all the movements of the cla- 

* Sur lesfract. de V acromion, in my Journal de Chirurgie, 1845, p. 178. 



A TREATISE ON FRACTURES. 409 

viele, and at the same time the separation at the point of fracture 
increased so as to receive the ends of two fingers ; this separation 
diminished, on the contrary, when the arm was carried outward and 
backward ; in all these movements the acromion did not incline either 
way, but kept always its original direction. When the head was held 
straight, the shoulder seemed hardly altered to the sight, and the arm 
retained its normal position. 

After this description from nature, it will be well to mention some 
points furnished by authors, which they have perhaps been enabled 
to observe, and which need verification. Bichat says that the head 
is turned from the injured side, — this is at least not constant. Sir 
A. Cooper says that the patient, immediately after the accident, feels 
great weight of the shoulder, and as if his arm was going to fall ; he 
adds that the head of the humerus sinks into the axilla as much as 
the capsular ligament will allow, and lastly that the distance is les- 
sened between the sternal end of the clavicle and the point of the 
shoulder. 'I do not know how to reconcile this shortening, which 
would imply a more or less notable overlapping, with the separation 
of the fragments mentioned by almost all obseryers. 

Finally, there remains one phenomenon of no minor importance 
in the diagnosis ; I allude to crepitation. Sir A. Cooper was the 
first to speak of it. If the surgeon raises the arm, lifting up the 
elbow, so as to give the shoulder its normal form, and then, placing 
one hand over the acromion, puts the arm through movements of 
rotation, he will according to Sir A. Cooper perceive a distinct cre- 
pitus. Lonsdale says he sometimes obtained it by alternately push- 
ing up the head of the humerus against the acromion and lowering 
it, or by separating the elbow from the body; or again, when these 
plans failed, by bringing the arm outward and elevating it as high 
as possible. 

It would seem that with all these ideas our diagnosis ought gene- 
rally to be clear, and yet this fracture has been frequently misun- 
derstood. Sometimes this is owing to the swelling, as in one of 
Duverney's observations, and in another of Lonsdale's ; we should in 
that case wait till it subsides before pronouncing a positive opinion. 
It may be easily seen also that when the fragments are not separated 
the surgeon is very liable to err, and cannot arrive at anything but 
a probable diagnosis. But Sir A. Cooper relates a case in which the 
fracture and an accompanying luxation of the clavicle both went 
undetected; and I have given in my Journal de Chirurgie an ac- 
count of a fracture of the acromion, supposed during life to be a 
luxation of the humerus, and discovered only at the autopsy. Such 
errors are deplorable, and prove at least great carelessness. 

The nature of the cause, the ecchymosis, and the local pain, put- 
ting us on the track, we should explore with the finger the entire 
length of the spine of the scapula; if there is prominence and sepa- 



410 A TREATISE ON FRACTURES. 

ration, there is no room for doubt; if not, we should seek to move 
the outer fragment from one side to the other, or from above down- 
ward, or to obtain crepitation in any way whatever. The mere per- 
sistence of the pain induced Duges, several months after a fall, to 
suspect a fracture of the acromion, without any crepitation or in- 
equality ; and the almost instant disappearance of the pain upon the 
application of a suitable apparatus, confirmed this bold diagnosis.* 
In fractures with notable displacement, I would advise also measur- 
ing from the acromion to the epicondyle, which is the real test of 
the depression; or measuring from the acromion to the sternum, 
if there is such a thing as overlapping, as Sir A. Cooper would lead 
us to suppose. The influence of the various motions of the arm 
upon the fracture needs also to be attentively studied. 

The views of authors as to the prognosis are very contradictory. 
Heister and Boyer regard it as impossible to obtain exact union with- 
out any deformity; but while the former thinks that the movement 
of elevation of the arm remains always impeded, the latter says that 
a slight distortion would not at all compromise either the motion or 
the power of the limb. In Desault's patient, indeed, all the diffi- 
culty had vanished by the forty-eighth day ; M. Janson even obtained 
a cure as complete in thirty days, in a much more difficult case ; the 
acromion had been divided by a sabre-cut, and the skin had to be 
brought together with a twisted suture.f 

Sir A. Cooper has pointed out another danger; osseous union, 
according to him, is rare in these fractures, and pseudarthrosis most 
commonly results. He relates a case of this kind ; MM. Nelaton 
and Avrard have each seen one ; osseous callus is wanting likewise 
in the specimens represented in Figs. 22, 23, and 25, and in another 
preparation in the Muse'e Dupuytren. Perhaps in these different 
cases we should generally be right in blaming either some bad 
complication, or the patient's intractability; in fact, in Bichat's 
case, consolidation was complete by the thirty-second day ; one of 
M. Avrard' s cases, although the bandage had been left off on the 
tenth day, had likewise subsequently firm union ; I have myself seen 
a remarkable case, in which it was impossible to detect by the touch 
the seat of the fracture. I think a distinction should be established 
between fractures without displacement and almost without injury of 
the periosteum, and those which offer the contrary conditions ; but 
even in the latter the treatment made use of, and the docility of the 
patient, would doubtless greatly influence the results. 

"When the callus does not ossify, Sir A. Cooper says that the 
fragments become connected by fibrous tissue. I have clearly made 
out this mode of union in the specimen represented in Figs. 22 and 

* Journal Univ. et ITebdomadawe, 1831, tome iv, p. 201. 

f Compte-rendu de VHotel-Dieu de Lyon, from 1818 to 1820, p. 20. 



A TREATISE ON FRACTURES. 411 

23; but in that from which Fig. 24 was taken, the fractured surfaces 
seem eburnated, as if they had rubbed against one another, and I 
incline to the belief that a joint had been formed. However this 
may be, it may be well to note that in all the specimens I have seen, 
the upper edges of the fracture have been surmounted by little ridges 
of new-formed bone, of which the larger part belonged to the scapu- 
lar fragment, (see particularly Fig. 25 ;) so that at first one would 
suppose that the process of ossification was more active here, and 
that the detached portion possessed less vitality. But another 
specimen in the Muse'e Dupuytren presents a strange phenomenon, 
obliging us to modify this conclusion. The outer fragment has a 
thickness nearly double that of the other ; so that while its superior 
face is on the same level with the latter, the inferior one descends 
much below it ; which has misled the editor of the Catalogue into 
calling it overlapping. It is on the contrary a hypertrophy of the 
detached portion, a phenomenon never yet, to my knowledge, pointed 
out, and which we shall have again to remark in other fractures. 

Fracture of the acromion is reduced, when the outer fragment is 
inclined or depressed below the other, by seizing the arm near the 
elbow, and raising it directly upward; the head of the humerus thus 
pushes the detached part into place, and to maintain it so we have 
only to fix the arm in this position. 

J. L. Petit's entire apparatus consisted of a sling. Heister added 
to this an axillary pad, and a spica around the shoulder. Desault 
applied an axillary pad of equal thickness throughout, and a bandage 
like that for fracture of the clavicle. Delpech advised having the 
pad which was placed between the arm and the side thicker below, 
so as to carry the elbow outward and relax the deltoid ; but he pre- 
ferred keeping the patient in bed, with his arm elevated nearly to a 
right angle. Sir A. Cooper, following the steps of Delpech, would 
have the axilla left free, and a cushion put merely between the side 
and the elbow, so as to keep the latter outward and a little backward. 
M. Nelaton tried in one case Mayor's apparatus for the clavicle, 
which draws the elbow forward. 

I think myself that in most cases an ordinary sling is sufficient, 
aided if necessary by a body-bandage to fasten the arm against the 
chest. This was the treatment followed in the only case I have ob- 
served, and I have stated what the result was. If however in some 
exceptional cases reduction is found to be more complete when the 
elbow is carried outward, or backward, or in any other direction, we 
should of course prefer whatever apparatus will best keep up that 
position. I would merely remark that the shoulder should not be too 
much raised, for fear of giving the scapula that well-known position 
in which the external angle being pushed upward, the posterior looks 
downward and the inferior forward ; which would have the effect of 
separating the two fragments, and making them form an angle up- 



412 A TREATISE ON FRACTURES. 

ward. Perhaps also we might, while pushing up the outer fragment, 
hear the inner one down to meet it. Desault's bandage, passing up 
from the elbow over the injured shoulder, fulfils this indication very 
well, but is too liable to become relaxed. The little apparatus with 
buckles, spoken of in connection with fractures of the clavicle, would 
be exactly the thing here. 

Sir A. Cooper left the apparatus in place only three weeks; Boyer 
kept it on forty or fifty days. There is probably some exaggeration 
on both sides, and the space of thirty days would seem to satisfy 
all the indications. 



§ III. — Fractures of the Qoracoid Process. 

This fracture is extremely rare, and hardly occurs except along 
with other fractures, and with immense contusion of the soft parts ; 
so that the cases of it are generally very grave. Duverney relates 
the case of a girl aged 20, who fell into a quarry, and was found 
dead ; the autopsy showed a fracture of the coracoid process, and 
one of the neck of the scapula, besides fractures of several of the 
ribs. Fig. 23 represents a fracture of the coracoid process, joined 
with numerous fractures of the scapula and humerus ; the patient 
died before the callus had become solid. I have seen another in- 
stance, in which death was hastened by the occurrence of an enor- 
mous axillary abscess. A patient of the same kind, whose case is 
published by South, died on the fifth day; another, treated by Arnott, 
lived until the tenth.* Lastly, Boyer saw a fracture of the coracoid 
process, caused by a blow from the tongue of a carriage, in a man 
who died from the contusion of the soft parts ; in this case the frac- 
ture seemed to be the only one present. 

Boyer teaches that the fragment detached is drawn downward and 
forward by the pectoralis minor and coraco-brachialis muscles, and 
by the short head of the biceps ; and Sanson adds that if the contu- 
sion be but slight we may grasp the fragment, and thus detect at once 
mobility and crepitation. As to this, we may remark that the coraco- 
clavieular ligament, which is inserted into nearly the whole of this 
process, holds the fragments quite close to one another, unless it is 
itself ruptured ; and that pressure alone suffices to detect mobility, 
without trying to grasp the fragment, which would be exceedingly 
difficult. Monteggia treated a fracture of this process, which was 
recognised by the mobility and crepitation, although the fragments 
remained in contact ; no apparatus was applied ; he merely employed 
cataplasms, and the customary fomentations for contusion ; and re- 
covery ensued in a short space of time. 

* Archiv. Gin. de Mtdecine, 1840, tome vii, p. 364. 



A TREATISE ON FRACTURES. 413 

Our art possesses hardly any other resources; only it may be use- 
ful to put the arm into a sling, the elbow being drawn forward and 
inward, with the double view of lessening the tension of the muscles 
inserted into the coracoid process, and keeping all the neighboring 
parts at rest. 

Morelot says that he employed successfully, in one case, Desault's 
bandage for fractured clavicle, taking care to apply graduated com- 
presses over the broken process. It would be difficult to imagine 
anything more irrational ; and these compresses would only drive in 
the fragment, instead of keeping it in place. Moreover, the diag- 
nosis was very doubtful, and the real condition of the process was 
not ascertained either before or after the treatment.* 

[During my eighteen months' residence in the Pennsylvania Hos- 
pital, I saw six well-marked cases of fractured scapula. One was in 
a child two and a half years old, was caused by falling down three 
stairs, involved the neck of the bone, and united perfectly in two 
weeks. Another was in a man of about thirty, who had been struck 
by some falling boards ; it was near the neck of the bone, and the 
contusion was very severe; he went out in twenty-seven days, before 
his cure was completed. Another was in a man of twenty-six, who 
had been struck by the crank of a hand-car on a railroad ; there was 
much contusion, and the fracture was a comminuted one of the body 
of the bone ; it was entirely cured in thirty-two days. Another was 
combined with a fracture of the clavicle, in a man of about fifty-five ; 
it was seated in the body of the bone, and was caused by a fall down 
a cellar-way; he recovered the use of the arm in about six weeks. 
Another was in a woman aged 28, who fell down a flight of ten, 
stairs, and broke off the lower angle of the right scapula; she was 
completely well in seventeen days. The sixth and last was only dis- 
covered after death, in a negro man who was injured by the fall of a 
derrick, which had broken also his thigh, and the spinous processes 
of three vertebrae. It was comminuted, and partly fissured. In the 
second, fourth, and fifth of these cases, the fracture was on the right 
side ; and in the first, third, and last, it was on the left. The apparatus 
used in each case was merely such as would keep the arm still.] 

* Journal Gtntral de Mtdecine, tome xix, p. 287. 



CHAPTER XL 

FRACTURES OF THE HUMEEUS. 

These fractures are very common, ranking in this respect with 
those of the clavicle ; but the proportion of the two varies in diffe- 
rent years. Of our total of 2358 fractures, 317 were of the hume- 
rus, — more by nearly one-third than those of the clavicle ; but even 
at the Hotel-Dieu, in one of our three series of years, these latter 
fractures were in excess ; and at the Middlesex Hospital, Lonsdale 
counted 273 fractures of the clavicle to only 118 of the humerus. 
The influence of sex and age had much to do with these differences. 

Of 310 simple fractures of the humerus, 206, or two-thirds, were 
in males ; one-third only affected the other sex. 

Classing them according to age, we find : 

From 2 to 20 vears - - - - - - 45 

" 20 " 40 " SO 

" 40 li 60 " 105 

" 60 " 80 " and above .... 80 

Whence it may be seen that without being rare in infancy and 
adult age, they are notably more frequent in more advanced life; but 
women especially seem much more exposed to them in old age. Thus 
I have found : 

From 2 to 20 years, of 45 fractures, 9 women, = ±. 
" 20 " 45 " 105 " 28 " = |. 

" 45 " 60 " 80 " 29 " = more than i. 

" 60 " 80 " 80 " 38 " = nearly }. 

The influence of the seasons is very nearly the same as that of 
age ; for instance, eighty-nine fractures occurred in the three winter 
months, sixty-six in the three summer months; spring and autumn 
affording a mean between these two extremes. 

Fractures of the humerus present many varieties. Those of the 
great tuberosity come under the head of luxations, along with which 
they generally occur ; at the other extremity, those which enter the 
joint belong rather to the chapter on fractures of the elbow. It re- 
mains, therefore, for us to examine here: (1) extra-capsular fractures 
of the upper extremity, or of the cervix humeri ; (2) intra-capsular 
fractures, or those of the head of the humerus ; (3) fractures of the 
(414) 



A TREATISE ON FRACTURES. 415 

shaft ; (4) fractures of the lower extremity, or just above the con- 
dyles ; (5) fractures of the epicondyle. 



§ I. — Extra- Capsular Fractures, or those of the Cervix Humeri.* 

We call that part of the humerus the neck, which is comprised 
between the head and tuberosities on the one hand, and the insertion 
of the latissimus dorsi, teres major and pectoralis major, on the 
other. Some surgeons, and recently also Sir A. Cooper,f extend 
the term as far as the insertion of the deltoid, but without any reason 
or use. 

[In America, as in England, the humerus is said to have an ana- 
tomical and a surgical neck; the former the slightly constricted por- 
tion of the bone just above the tuberosities, and the latter comprising 
all below this as far as the insertion of the deltoid. This muscle 
exerts so marked an influence upon the deformity in any case of 
fracture above its lower attachment, that such an extension of the 
term surgical neck would seem to be entirely warranted.] 

Fractures of the neck may occur at different points ; one may be 
seen in Figs. 22 and 23, which is quite distant from the joint, and 
actually affects the shaft ; Sir A. Cooper has represented one of the 
same kind ; but these cases are rather rare, the fracture generally 
dividing the bone just where the junction of the diaphysis with the 
spongy portion is clearly defined, and where for this very reason less 
resistance is offered to any external violence. 

These fractures are among the most common of all ; for my own 
part, I have seen them nearly as often as those of the cervix femoris. 
They particularly affect old persons; the youngest patient I have 
treated with one was fifty-three years old, although they may occur 
at all ages. Sir A. Cooper even goes so far as to say that they are 
more frequent in infancy than in old age ; but this seems to me to be 
a great mistake. 

They are usually the result of direct violence, such as a fall, or a 
violent blow on the point of the shoulder. Two cases are, however, 
reported in Desault's journal, caused by falls on the elbow, and an- 
other by a fall on the hand ; and analogous cases have been cited by 
other observers. Moreover, M. Goyrand seems to have seen a frac- 
ture of the surgical neck from mere muscular contraction in throwing 
a ball ; though, to be sure, severe and deep-seated pains had been 
felt in the arm for six months previously. J 

* Malgaigne, Mim. sur lesfracb. de Vextr6rniU sup. de Vhumirus ; Journal de 
Chirurgie, Sept.. Oct., and Nov., 1845. 

f On fractures of the head and neck of the os humeri ; Guy's Hospital Re- 
ports. Oct., 1839. 

+ Tidal, Pathologie externe. tome ii, p. 114. 



416 A TREATISE ON FRACTURES. 

The direction of the fracture is generally transverse, with nume- 
rous serrations at its circumference; more rarely it is oblique, and 
then its direction is mostly from above downward, and from without 
inward, parallel to that of the anatomical neck; at other times again 
it is complicated with small splinters, or with fractures in other direc- 
tions, as, for instance, extending to the tuberosities. Lastly, some- 
times it is combined with fracture of the head of the bone; to this I 
shall recur in speaking of the latter. 

But a principal fact, and one which I think I have placed beyond 
doubt, is that whatever may be the anatomical form of the fracture, 
in the great majority of cases there is no appreciable displacement. 
The fragments are kept in position by the resistance of the perios- 
teum and of the long head of the biceps ; and among more than 
twenty fractures of this kind, I have seen but two in which the dis- 
placement was perceptible.* 

The nature of the displacements is quite variable. Most fre- 
quently the fragments do not more than half leave one another ; one 
end slides on the other by one-third or one-half of its thickness, and 
generally the lower fragment is carried inward or toward the axilla. 
(See Figs 22 and 23.) But it may also take the opposite direction; 
Desault saw it thrown backward; Dupuytren, Palletta, Duret, and 
others have seen it push up or even perforate the deltoid ; lastly, still 
more commonly, it projects forward, toward the coracoid process; of 
this M. Debrou has seen three cases in one year at the H6tel-Dieu in 
Orleans,f and Sir A. Cooper even makes it in children one of the 
constant phenomena of this fracture ; an assertion too contrary to 
known facts to need formal refutation. 

It is evident that such various displacements cannot all be attri- 
buted to muscular action. When the fracture is transverse, the only 
real cause of displacement is the impulsion given by the external 
force; when it is oblique, the displacement is generally influenced 
altogether by the direction of the obliquity, and there is added be- 
sides a more or less marked overlapping. But we must bear in mind 
that here the mobility of the head of the humerus upon the glenoid 
cavity may cause a change in the displacement, as well as in the 
direction of the fracture. In a very remarkable case observed by 
M. Gely, the lower fragment, which came to a sharp point, had per- 
forated the deltoid anteriorly, close to the interstice between it and 
the pectoralis major, and there had consequently been diagnosed a 
fracture, obliquely downward and backward. This was an error, as 

* [It may seem as though this paragraph were at variance with what follows ; 
but even if the cases in which there are displacements constitute a very small 
minority of the whole number, they may be sufficiently numerous to allow of 
great varieties among themselves.] 

t Debrou, Lettre sur une variU6 de dtplacement du fragment inftrieur, etc. ; 
in my Journal de Chirurgie, December, 1845. 



A TREATISE ON FRACTURES. 417 

it was in reality downward and inward, parallel to the plane of the 
anatomical neck. We should suppose then that the lower fragment 
would have projected outward, so much the more since it had pene- 
trated the spongy tissue of the other fragment. But the head of the 
humerus having undergone a rotary movement from before backward, 
by reason of the external violence, the lower fragment, attached to it 
externally, was drawn forward by its rotation backward ; it remained 
entangled in the tissues, and was thus found at the autopsy, which 
was made nearly eighteen months after the accident.* 

Thus it is then that, with a fracture obliquely downward and in- 
ward, the lower fragment may project sometimes outward, sometimes 
forward, sometimes even backward, from the external violence, and 
by rotation of the upper fragment, without the two ceasing to be 
in contact. Occasionally the lower fragment passes through the mus- 
cles and partially through the integuments, so that it is felt nearly 
bare beneath the finger; M. Gely has noted this circumstance, and 
similar cases have been seen by Palletta and M. Debrou. 

Lastly, the fragments may entirely abandon one another. Bichat 
says that he has seen the lower fragment carried upward with so 
much violence as to pierce the integuments and pass up much above 
the level of the head of the bone; and M. Gu£r£tin has published 
another case of this kind, to which I shall again refer directly. In 
general, the lower fragment is merely thrown into the axilla, pushing 
forward the pectoralis major; but there is one peculiar form of its 
displacement, which is perfectly represented in Fig. 33. 

This specimen was taken from an old man of seventy-seven, who 
died in my wards on the twenty-sixth day after the fracture, which 
it had been impossible to reduce. The lower fragment is in the first 
place seen to be thrown inward and forward, and in fact during life 
it pushed against the tissues close to the line between the deltoid 
and the pectoralis major, farther inward than the coracoid process; 
the overlapping was betrayed during life by shortening of the arm 
to the extent of nearly an inch. The fracture was seated below the 
tuberosities and the capsular ligament, which latter was nowhere 
opened, and about an inch above the insertion of the pectoralis 
major; it was transverse, with numerous serrations around its edges; 
and Fig. 34 shows a splinter which had been detached from the 
lower fragment and buried within the upper, as seen in Fig. 33. 
This upper fragment, free from any adhesion, had been drawn up by 
the supra-spinatus and probably by the other scapular muscles into 
such a rotation upward and outward that the great tuberosity is 
buried under the acromion; the fractured surface looks outward and 

* Gely. Fract. du col anat. de V humerus ; Journal de CJu'r.. 1844, p. 315. 
This title is inaccurate, as the author himself remarks in the course of the 
article. 

27 



418 A TREATISE ON FRACTURES. 

even a little upward, and the articulating head is turned inward and 
downward. I have detached the capsular ligament on this side so as 
to make this arrangement more distinct. In a word, the upper frag- 
ment is in a position answering to the greatest elevation of the arm 
in the normal state ; the lower, on the contrary, in a position an- 
swering nearly to its greatest depression ; it may be seen that this 
latter is in contact with the capsular ligament, and that by drawing 
it downward nothing would be gained but to get it below the cap- 
sule. The dotted lines running upward and outward show the exact 
position into which the lower fragment would have to be brought, in 
order to exert rational traction, and bring the fractured surfaces into 
perfect contact. I must not omit to say that the long head of the 
biceps would not allow such a displacement to occur, unless it had 
been turned out of its sheath ; and on the lower fragment may be 
seen the transverse depression hollowed out by it in the swollen 
periosteum, as it thus goes round to reach its place of entry into the 
capsule. 

When the fracture exists without perceptible displacement, the 
symptoms are : quite severe pain in the shoulder, increased by pres- 
sure or by the slightest movement ; incapability of voluntary motion ; 
swelling of the shoulder ; ecchymosis ; and lastly crepitation. 

The impossibility of movement is not always absolute, and some 
patients can still carry the arm in different directions to a slight ex- 
tent. The swelling is sometimes considerable enough to mask the 
displacement, and even to prevent our hearing crepitation; of this I 
have recently seen an instance. It appears to result mainly from 
effusion of blood beneath the deltoid, making the muscle bulge out- 
ward, and singularly increasing the concavity of the external surface 
of the arm below. The ecchymosis demands special attention. Some- 
times it is present on the first day ; frequently only after several 
days. It may show itself on the inside, in front, behind, or on the 
outside of the arm, and commonly it occupies several of these posi- 
tions at once; sometimes it is limited to the point of the shoulder, 
and again it may invade the whole arm, or even extend to the walls 
of the chest. It is very rarely entirely wanting ; and I have seen but 
one case in which the fracture was attended with only a very slight 
ecchymosis below the clavicle. A fact of importance as to the prog- 
nosis is, that except in the few cases in which the ecchymosis was 
hardly perceptible, I have generally seen it persist beyond the time 
required for consolidation; so that the patients recovered from the 
fracture before they did from the ecchymosis. 

All these symptoms cannot however warrant more than a probable 
diagnosis ; crepitation alone can make it positive. This is best eli- 
cited by grasping the elbow and rotating the arm in different direc- 
tions successively. It is but rarely that it cannot be thus communi- 
cated to the other hand grasping the point of the shoulder; and 



A TREATISE ON FRACTURES. 419 

sometimes it is extremely well marked, probably when the fracture is 
attended with splintering. 

When there is transverse displacement merely, the symptoms re- 
main the same, except the projection of the fragments, and the in- 
clination of the elbow in the opposite direction to that of the other 
end of the lower fragment. When there is overlapping added to this, 
we ascertain it by measuring the anterior wall of the axilla, from the 
clavicle to the edge of the fold, or by measuring the arm from the 
posterior angle of the acromion to the point of the epicondyle; ob- 
serving the precautions necessary in the diagnosis of fractures gene- 
rally. The diagnosis is still more clear when the fragments are en- 
tirely separated; the presence of the head of the bone under the 
acromion; a depression below the head, the shortening of the arm, 
and the mobility in all directions of the lower fragment, preclude all 
idea of a luxation; and in the case represented in Fig. 33, there was 
not even any prominence in the armpit. 

These fractures, when there is little or no displacement, consoli- 
date rapidly, not requiring for this more than thirty days. But 
there remains long afterwards a stiffness, and a difficulty in moving 
the shoulder; and however great care may be taken, the motion of 
elevation of the arm will always remain limited; at least I have in 
no case seen it perfectly restored, even after the lapse of from eleven 
to fifteen months. Besides the share taken by the joint in the irri- 
tation excited by the fracture, pathological anatomy has shown me 
another cause of this loss of motion ; it is a particular form of dis- 
placement, so slight that it is not revealed by any symptom during 
life, but very apparent when the bone is quite stripped of the soft 
parts. Fig. 30 represents it perfectly. 

In this humerus, sawed vertically through the middle, the fracture, 
which is of very ancient date, seems to have divided the bone just at 
the junction of the compact with the spongy portion. Thus the head 
and the tuberosities have undergone no change of shape; only by 
comparing them with their normal direction, (indicated by the dotted 
line,) we see that they have been displaced inward by nearly a centi- 
metre, and that* at the same time the greater tuberosity has been 
carried upward, and the head inclined downward on the inner side of 
the shaft. The upper fragment has therefore gone through a rota- 
tion like that shown in Fig. 33, just described, but arrested when at 
a very slight degree by the resistance of the lower fragment, the 
inner portion of which seems buried in the spongy tissue of the head 
of the bone. This is an actual penetration, appearing here much 
more considerable than it really is, owing to the neck being carried 
along the inner face of the shaft. The neck has left on the outside 
some irregularities which do not appear in the figure, and has even 
at one point completely filled up the bicipital groove. But the 
essential and ineffaceable result of the displacement has been to 



420 A TREATISE ON FRACTURES. 

limit, by nearly a centimetre, that motion of the head of the hu- 
merus on the glenoid cavity which constitutes elevation of the arm, 
and thus to restrain the extent of this elevation. I have seen several 
other analogous specimens, and shall recur to them in the next 
article.* 

When there is overlapping and projection of the lower fragment, 
the formation of callus still occurs between the portions which remain 
in contact, but it is less solid, as would be supposed; M. Letenneur 
exhibited to the Societe Anatomique a callus of this kind, dating 
back five years, which had been gradually destroyed by absorption, 
and was at last broken toward the close of life; the patient was 
however affected with cancer. f As to the point projecting beneath 
the integuments, it is quite promptly reduced and removed by ab- 
sorption. 

When, finally, the fragments are entirely separated, it may occur 
that from the attempts at reduction very grave suppurative inflam- 
mation is set up in the cellular tissue of the axilla ; it was such an 
accident which carried off my patient. When all danger of this kind 
has gone by, but the broken ends remain displaced, a case observed 
by M. Danyau may teach us what to expect. The arm was short- 
ened by an inch, its movements rendered difficult, and that of rota- 
tion impossible ; the hand could not be carried to the top of the 
head, nor the elbow brought in to the side. 

From all that precedes, it is evident that in the majority of cases 
there is no reduction to be made, since no displacement can be de- 
tected. When the fragments are somewhat deranged, but still remain 
interlocked, it is necessary to make sufficient extension to enable us 
to bring them back into their proper relation ; and perhaps the trac- 
tion could be made to better advantage with the arm raised nearly at 
a right angle, and the forearm semiflexed, the muscles being thus 
relaxed. In one case in which the lower fragment was caught in the 
skin, all efforts to disengage it having failed, the surgeon, M. Vallet, 
of Orleans, made a small puncture at some little distance off, carried 
a narrow probe-pointed bistoury between the bony point and the 
skin, and divided the bridles of tissue retaining the point without 
otherwise injuring the skin ; the little wound was covered with lead- 
plaster, and healed without any suppuration taking place. This 
result deserves to be compared with the failure of an analogous plan 
before mentioned, (see page 162.) 

But if we have to deal with fragments completely separated, we 
must resort to manoeuvres more precise than those laid down in the 
books, and, moreover, attempted in a different way. According to 
the attentive examinations I have made of the distorted position of 

* Sir A. Cooper has had represented a specimen of the same kind; (loc. cit., 
pi. vi;) but without comprehending its significance. 
t Bull, de la Socitte Anatomique, July, 1838. 



A TREATISE ON FRACTURES. 421 

the superior fragment, proper extension could not be made except 
by raising the arm outward to more than a right angle, so that the 
elbow should be above the extended axis of the clavicle. In this 
way alone can we hope to bring the fractured surfaces into contact ; 
and probably if this contact were once obtained, the fragments might 
become so interlocked that the arm could be brought down close to 
the trunk, and into a less painful position. But I cannot too much 
insist on the fact that by drawing upon the arm while it hangs close 
to the trunk, nothing is gained except to bring the lower fragment 
against the capsular ligament. 

In order to maintain the reduction, two things are to be attended 
to : the position of the limb, and the apparatus. Before the eighteenth 
century, there were three principal methods, viz., that of Duverney, 
who kept the patient lying on his back, with his arm supported at a 
right angle by cushions ; that of Moscati, who likewise kept the 
patient in bed, with his arm supported upon cushions, but only 
slightly separated from the trunk ; and that of Ledran, who fixed 
the arm parallel to the trunk, putting between them a sort of pad of 
linen, one finger's-breadth in thickness. Desault subsequently com- 
bined Moscati' s method with that of Ledran, giving the pad the 
form of a wedge, whose base, three or four inches thick, being 
placed opposite the elbow, held the lower end of the arm far- 
ther from the side than the upper ; Boyer, on the contrary, turned 
the base of the wedge upward, so as to bring the elbow toward the 
side and push the upper extremity outward. Dupuytren followed 
Desault with regard to the position of the limb ; Richerand carried 
out B oyer's idea still further, by bringing the elbow inward and for- 
ward, the hand being laid on the sound shoulder. 

Now, since we understand the relative position of the two frag- 
ments even in the simplest fractures, we may at once exclude Boyer's 
method, and much more that of Richerand, as utterly irrational. 
Since the fragments already tend to form an angle opening inward, 
the more we bring the elbow farther in than the top of the humerus, 
the more we increase this angle ; Desault and Dupuytren therefore 
showed, I do not say better views, but better judgment, by keeping 
the elbow outward. And yet such slight abduction would not seem 
fitted to replace the lower fragment when more or less entangled 
with the other ; and I would about as soon leave the arm close to 
the trunk. 

As for the apparatus, the simpler it is the better. Rest in bed is 
by no means necessary ; the spica, the pads, and the splints are en- 
tirely useless ; it is sufficient merely to keep the forearm in a sling, 
not raising the elbow too much lest we increase the angle of the 
fragments ; and a body-bandage may be added so as to insure more 
perfect immobility. I cannot understand the use of splints except 
when the lower fragment projects either anteriorly or posteriorly ; then, 






422 A TREATISE ON FRACTURES. 

indeed, the splint applied over the prominence would tend to push it 
into place, while the other splint would do the same for the other 
fragment. They may easily be fastened around the arm below, and 
above over the shoulder, beyond which they ought to reach. 

[A very excellent plan for the treatment of all fractures of the 
humerus near its upper extremity, is to use an inside angular splint, 
a wedge-shaped pad, the size of which should be regulated by the 
amount of deformity to be overcome, and a pasteboard cap for the 
shoulder. Reduction being made as carefully and completely as pos- 
sible, the splint is fitted to the arm, the pad being so arranged at its 
upper end as to obviate the displacement; these being now bound to 
the arm by a roller, the cap, well padded, is laid over the shoulder, 
and by turns of a wide roller over the shoulder, upper part of the 
injured arm, and body, the dressing is completed. Should the lower 
fragment project forward or backward, the padding of the cap may 
be so disposed as to make pressure at any desired point. Very good 
results have been observed from the use of this method in the Penn- 
sylvania Hospital and elsewhere.] 

The overlapping in oblique fractures is more difficult to overcome, 
and our only means of doing this is by permanent extension. Two 
methods have been devised: traction and leverage. M. Coillot makes 
traction as follows: 

His apparatus consists essentially of (1) a stick of wood of the 
thickness of a finger, placed vertically in front of the shoulder, 
above which it extends, and reaching down below the elbow, passing 
behind the semiflexed forearm; (2) of two tapes, two fingers'-breadths 
wide ; (3) of cushions for the axilla and elbow. One of these cushions 
is put into the axilla, and so folded before and behind as to press as 
much as possible only in these two directions. In order better to 
secure this object, it is covered before and behind with two bits of 
pasteboard, and the whole bound together by the first of the two 
tapes, the two ends of which pass up to be fastened at the top of the 
stick; this makes the counter-extension. The bend of the elbow being 
well protected by the other cushion, the second tape is applied to it 
in the form of a figure-of-8, whose two ends are fastened at the lower 
end of the stick so as to make extension. It should be remarked 
that the tapes are fastened by means of a buckle above and below, 
so that the loops may be tightened or loosened at will. Lastly, in 
order better to avoid pressure beneath the axilla, M. Coillot passed 
through the loop of the upper band a small tape, called by him lacs de 
rappel, which, going down to be fastened to the stick, drew the loop 
away from the axilla, preventing it from pressing except upon the 
folds anteriorly and posteriorly. 

In spite of these precautions, the patient suffered much from 
pressure, especially about the elbow ; the fingers grew numb, and 
the whole extremity began to swell, till at last the symptoms became 
so severe that the apparatus had to be removed. The author adds, 



A TREATISE ON FRACTURES. 423 

however, that the reduction was permanent, and that the overlapping 
was so completely overcome that the arm even presented a slight 
excess in length. 

M. G4\j has tried the lever-method in the following manner: 
with three splints nailed together by their ends, he constructs a solid 
triangle whose apex presents an angle of somewhat more than 90°. 
The base of this triangle is placed along the side, which is duly pro- 
tected ; its lower angle reaches the crista ilii, its upper, well padded, 
the axilla ; one of its shorter sides serves as an inside splint, and 
carries the arm away from the body ; the apex of the triangle, di- 
rected outward, occupies the bend of the elbow, at a distance of 
twelve centimetres from the side, and lastly, the forearm fits along 
the third splint. In this apparatus, the axillary angle bears against 
the outer edge of the scapula, so as to make counter-extension ; the 
forearm is the lever, which, working over the outer angle, draws out- 
ward the elbow and the lower fragment, — the length of the humeral 
splint being so calculated as to produce this effect in the most satis- 
factory manner. 

This apparatus was applied in the case of a woman aged 29, who 
had an oblique fracture of the cervix humeri, the lower fragment 
projecting forward quite close to the skin. The patient was laid on 
a perfectly flat bed, and the elbow raised by means of a cushion, so 
as to carry the lower fragment backward. She showed great tracta- 
bility, and the apparatus seemed to have the effect of preventing the 
upward projection of the fragment, which had threatened to pierce 
the skin ; but on the whole,' after it had been kept on for forty days 
the projection was apparently about the same. 

This result is less brilliant than that in M. Coillot's case; perhaps 
it is nearer to the sober reality. We might doubtless resort to either 
apparatus, but the prudent surgeon will abstain from promising com- 
plete success. 

It appears that in an analogous case, Tyrrell succeeded in correct- 
ing the deformity and insuring coaptation, by supporting the arm 
upon one branch of a rectangular splint, the other branch being ap- 
plied along the trunk;* this is the position recommended by Duver- 
ney, and would be a valuable resource in case of necessity. 

Whatever apparatus we employ, we should not, at least in ordi- 
nary cases, leave it on for more than thirty to thirty-five days; and 
soon after this we should commence exercising the joint. It is pru- 
dent also, even while the apparatus is in place, to make at times 
passive motion of the elbow, wrist and fingers, so as not subsequently 
to have to combat stiffening of them. 

Fractures of the cervix humeri can hardly be complicated with a 
wound [or, as it would be expressed in England or in the United 
States, be compound,] except as the effect of gunshot; although 

* A. Cooper, op. cit., p. 283. 



42-4 A TREATISE ON FRACTURES. 

M. Gueivtin has reported an instance in which the wound was caused 
by the lower fragment piercing through the deltoid and the integu- 
ments; the patient was injured by the caving in of a gravel-bank. 
The purulent discharge from this wound was enormous; amputation 
was performed on the forty-ninth day, and death ensued on the 
sixty-third. It is remarkable that the amputation was intended and 
supposed to have been done through the joint, but at the autopsy 
the head of the bone was found in place ; its end was hollowed out 
to the depth of about one-third of an inch, and this concave surface 
had been mistaken for the glenoid cavity.* 

I shall say but a few words concerning the separation of the epi- 
physis, which in young subjects sometimes occurs instead of fracture 
of the cervix. I have elsewhere mentioned (p. 69 et seq.) all the 
cases known to the profession ; there are only four or five, showing 
how rare this lesion is ; moreover, in the only specimen to be found 
in our museums, and which is represented in Fig. 4, there is a slight 
accompanying fracture. The causes are violent tractions, or falls; 
never, at least hitherto, direct blows. The symptoms are the same 
as those of transverse fractures, so that there is always some doubt 
as to the diagnosis in the living subject. A very peculiar result, 
observed by Bertrandi and by Chapelain-Durocher, was the fusion of* 
the cartilaginous epiphysis with the glenoid cavity; so that in place 
of a cavity the scapula presented a rounded articular eminence, re- 
ceived into a new cavity hollowed out in the extremity of the diaphy- 
sis. In Chapelain-Durocher's patient, the disjunction occurred during 
birth, and the child lived only fourteen months; the body of the 
humerus was shortened by one-quarter, and the muscles of the 
shoulder notably atrophied. A still more marked paralysis of the 
arm resulted in the patient observed by me, whose age was fifty- 
seven years ; and yet the epiphysis and diaphysis were firmly united. 
These cases should be carefully noted, but owing to their small 
number we are not warranted in drawing any general conclusions 
from them. 



§ II. — Intra- Capsular Fractures, or those of the Head of the Bone. 

Fractures of the head of the humerus are much more rare than 
those of the cervix; they present several varieties. 

In Fig. 23, there is seen, among other fractures, a transverse fis- 
sure of the head, penetrating to a depth of more than two-thirds of 
an inch. An autopsy alone could reveal the existence of such a 
lesion as this. 

There are several cases reported of fractures entirely within the 



* Presse Medicate, 1837, p. 84. 



A TREATISE ON FRACTURES. 425 

joint, and which all, curiously enough, have separated the bone 
through its anatomical neck. Boyer states that he has seen several 
cases; and death was the unfailing result. In those cases which 
survived the longest, and especially in a woman who died on the 
seventh day, the head of the bone had undergone a remarkable 
wasting, being reduced so as just to fit the glenoid cavity. The 
same author states that the upper fragment does not at all contri- 
bute to the work of reunion. It is evident that if the head were 
absolutely separated from the rest of the bone, it could not in any 
way be reunited to it; but if the periosteum of the anatomical neck 
remains entire over the fracture, consolidation may become com- 
plete; M. J. Cloquet has exhibited a fracture of this kind occurring 
just between the head and the tuberosities, perfectly united, although 
with slight deformity.* 

These fractures, limited to the anatomical neck, may be detected 
by the presence of crepitation, but are with difficulty distinguished 
from others, if there is little or no displacement. The only great 
displacement which has been observed consists in an actual luxation 
of the head through the capsule, either forward or backward, the 
neck of the bone remaining applied against the glenoid cavity; to 
this I shall recur in connection with luxations. 

Most commonly, fracture of the head is combined with that of the 
neck ; and it is at once intra and extra-capsular. In all these cases 
the cause is a direct blow ; generally a fall on the shoulder. But 
the phenomena are various, according to the violence and to the 
mode of action of the fracturing cause; hence result two principal 
forms. 

In the first, sometimes the fracture, following the direction of the 
anatomical neck, on one side enters the capsule and on the other 
remains outside of it; thus Bichat saw the humerus of a young man 
of seventeen, in which the head was separated from the shaft by a 
division which involved somewhat also the upper portion of the 
tuberosities ; and such would seem to me to be the nature of the two 
cases figured by Reichel under the very inaccurate name of epiphy- 
seal detachments. Sometimes there is a transverse or comminuted 
fracture of the cervix; or, again, a second fracture penetrating 
within the capsule and dividing the head into two parts; this seems 
to me to have occurred in the specimens represented in Figs. 28, 29, 
31 and 32. 

We find therefore, whether during life or after death, on the one 
hand all the symptoms of fracture of the cervix, and on the other, 
some which are peculiar to that of the head of the bone. This is 
especially set forth in Figs. 31 and 32, which represent the same 
specimen. In Fig. 32, the greater tuberosity is seen to be carried 

* Bulletins da la FacvlU, 1820, p. 25. 



426 A TREATISE ON FRACTURES. 

upward and inward, the head inclined inward and downward, and the 
inner wall of the diaphysis interlocked with the spongy tissue of the 
other fragment, almost as in Fig. 30; here are all the symptoms of 
fracture of the cervix merely, except shortening to about a milli- 
metre and a half. But Fig. 31, a posterior view of the same pre- 
paration, shows the roundness of the head of the bone altered by two 
squamous projections, manifestly two fragments improperly united, 
and rising two or three millimetres from the rest of the articular 
surface. 

Here the fracture of the head of the bone was behind; Fig. 28 
shows one in front, having the characteristics of fracture of the 
neck, the head inclined inward and downward, together with those 
of fracture of the head, the detached fragment projecting forward. 
Fig. 29, by a peculiar section, shows how deeply the two fragments 
have penetrated one another, and that the outer one passes the sur- 
face of the other above and in front by four to six millimetres. 
There was no appreciable shortening. 

During life, therefore, the signs will be at first those of ordinary 
fracture of the cervix, except perhaps more marked crepitation, the 
fragments being in greater number; but there is besides a widening 
of the head of the bone, mainly revealed by an abnormal prominence 
anteriorly, below the coracoid process. Sometimes this prominence 
corresponds to a depression below the posterior angle of the acromion ; 
sometimes also the shoulder seems a little flattened. In some cases 
the prominence in front is wanting, and is replaced by one poste- 
riorly; and finally these prominences may both be absent, or so 
slight as not to be perceptible during life. We see therefore that 
we should often be likely to confound these fractures with those of 
the cervix, but just in<those cases in which the error would be of the 
least importance ; the only means of arriving at a precise diagnosis 
is to detect some deformity [or mal-position] of the head of the 
bone. 

We must however guard against another error, and not confound 
a fracture with a luxation. A woman aged 82 fell down on her left 
shoulder; a good deal of swelling ensued, almost preventing the 
acromion from being felt ; another prominence was detected in the 
axilla; the elbow was carried outward, and the arm shortened by 
half an inch. A luxation was diagnosed, and the axillary promi- 
nence was actually caused to disappear by attempts at reduction. 
But the patient dying on the eleventh day, there was found a frac- 
ture of the cervix humeri, with separation of the head of the bone 
into three fragments, held together by the uninjured periosteum and 
capsule. 

The shortening of the arm, the slight depth of the sub-acromial 
depression, and lastly the crepitation, form the chief grounds of the 
differential diagnosis. 



A TREATISE ON FRACTURES. 427 

The treatment is the same as for other fractures of the cervix; 
only we should seek to replace, bj means of proper traction and 
pressure, any fragments which project either before or behind. Con- 
solidation occupies a somewhat longer time, because of the less 
vitality of the upper fragment; sometimes even when there is great 
separation outwardly between the fragments, as in Reichel's two 
cases, the callus remains in great part merely fibrous. We must 
also generally expect more stiffening of the joint, either from the 
irritation necessarily occurring in it, or from the changed relations 
of the fragments. 

In the form just alluded to, the head remains permanently pro- 
jecting inward from the diaphysis, and commonly its natural promi- 
nence in this direction is increased. In the other form, on the 
contrary, the head of the bone is at once crushed and thrown out- 
ward, as if the external violence, after acting upon it, continued to 
act on the diaphysis, driving it inward. 

Fig. 26 represents a fracture of this kind. The tuberosities, 
separated at once from the head and shaft of the bone, are divided 
into three fragments held together by the periosteum, but evidently 
displaced outward. The head, nearly separated from the anatomical 
neck, and partly crushed, has been turned in the same direction ; its 
lower edge is partly lodged in the medullary canal, and the rest pro- 
jects back of the diaphysis, the edge of the wall of which has deeply 
penetrated it. The diaphysis, carried upward and inward, is in con- 
tact with the lower portion of the glenoid cavity. The capsule, how- 
ever, remains intact, being only stripped off within and posteriorly, 
along with the periosteum, to the extent of one or two centimetres ; 
it was divided intentionally, so as to display the fracture. 

Fig. 27 represents a similar lesion, but in a humerus isolated and 
stripped of all the soft parts; it shows clearly what the preceding 
figure left obscure. The crushing is perhaps a little less ; but the 
outward displacement is more marked, and the diaphysis makes a 
more considerable projection inward. The curved dotted line shows 
the normal prominence of the head of the bone, and shows better the 
extent of the combined crushing and displacement. 

In a still more marked case, the tuberosities are entirely separated 
from the rest of the bone, and the head applied like a cap over the 
upper end of the diaphysis. I have before me a drawing of such a 
fracture, sent me by M. Thierry. 

What is the final result of such a lesion? Most commonly death 
ensues, not so much from the fracture itself as from the concomitant 
injuries due to the external violence; in the three specimens first 
spoken of, the fractures were quite recent, and I presume that in 
the cases of fracture of the anatomical neck spoken of by Boyer, 
there was an equal degree of crushing. All the patients, however, 



428 A TREATISE ON FRACTURES. 

do not succumb; but as to this point our information is excessively 
scanty. 

In the Muse*e Dupuytren, (No. 78,) may be seen a humerus enor- 
mously flattened in its upper fourth, with obliteration of the medul- 
lary canal, distortion of the neck of the bone, and in place of the 
head a corrugated, nearly flat surface; so that I should suppose 
crashing of all these parts had occurred, with separation of the head 
from the anatomical neck and the formation of a false joint between 
the fragments. But the want of all particulars, and the loss of the 
scapula and of the fragment which if this conjecture be right should 
represent the head of the bone, have prevented my having this speci- 
men sketched. 

Another specimen (No. 79,) shows a crushing analogous to those I 
have had represented; there is a commencement of callus; but it is 
far from being completed, and death probably took place in a few 
weeks. 

Lastly, Sir Astley Cooper has given an account of a patient who- 
survived his accident two months. In consequence of a severe fall, 
the shoulder swelled enormously ; a depression was however thought 
to be detected in the belly of the deltoid, and a tumor above the 
coracoid process ; a distinct crepitus was heard, and ascribed to frac- 
ture of this process ; the arm was shortened one inch. It would seem 
that luxation was suspected; traction was therefore made, and the 
bones replaced without much difficulty. The swelling gradually 
went down, and at the end of some weeks it was seen that the 
shoulder was flattened, and that a large hard tumor occupied the 
place of the coracoid apophysis. The slightest movement caused in- 
tense pain. About the fifth week passive motion was tried; and in 
three weeks the arm had recovered considerable mobility, but still it 
could not be raised above the level of the shoulder, or carried for- 
ward across the chest. An apoplectic attack destroyed life at about 
the sixty-second day. 

The autopsy, which is very badly described, is happily eked out 
by the drawing. There was a fracture of the acromion, and another 
of the coracoid process, both united by fibrous tissue. The head of 
the humerus, broken off through the anatomical neck, with a portion 
of the tuberosities attached, would seem from the drawing to have 
been turned outward and laid upon the extremity of the diaphysis, 
as in M. Thierry's case; and the callus was begun at once in the in- 
terior by the spongy tissue, and at the outside by a considerable 
quantity of ossifiable matter deposited by the periosteum. 

We can understand why union should occur in all cases in which 
the fracture, descending below the capsule, leaves to the head of the 
bone its connection with the periosteum; when it is otherwise, the 
head acts as a foreign body; but facts are wanting to show how 
nature would get rid of it, if such a thing were possible. 



A TREATISE ON FRACTURES. 429 

[An excellent article on the whole subject of this and the preced- 
ing section, may be found in R. W. Smith's " Treatise on Fractures 
in the Vicinity of Joints, etc.;" a case related there, (ed. of 1854, 
p. 201,) is remarkably similar to one treated in the Pennsylvania 
Hospital in 1855.] 



§ III. — Fractures of the Shaft of the Humerus. 

The most usual causes of these fractures are such as act directly 
upon the bone ; as a blow with a stick, a fall, the arm striking some 
prominent object, the passage of a carriage-wheel over the limb, etc. 
More rarely, the bone is broken indirectly, as by a fall on the wrist or 
elbow. Finally, there are some exceptional cases in which muscular 
action has a large share, and the mechanism of which demands 
serious study. 

Sometimes two persons want to test their strength of wrist. They 
place themselves facing one another, their elbows resting on a solid 
plane, their forearms touching by their ulnar margins, their fingers 
interlocked, and in this position each tries to turn outward the wrist 
and forearm of his opponent. In this struggle, there is first of all 
strong contraction of the flexors of the fingers, to resist extension, 
and of the pronators, to resist supination, and it is to be remarked that 
these muscles are mostly inserted into the epitrochlea. If they 
fix the forearm firmly, the turning can only be accomplished by ro- 
tation outward of the humerus; to prevent this, the muscles of the 
arm, and especially the latissimus dorsi, pectoralis major and deltoid, 
are thrown into powerful action ; if their resistance is not overcome, 
all the efforts of the opponent will tend to twist the humerus, at 
some point between the epitrochlea and the insertion of the deltoid. 
Debeaumarchef read to the Academie de Chirurgie, in 1791, the 
first account known of fracture of the humerus by such a cause; 
M. Caffort addressed a similar observation to the Academie de Me- 
decine, in 1827;* Lonsdale reports two others, and I myself quite 
recently saw another. The fracture is generally seated two or three 
inches above 'the condyles ; and according to the above account of 
its mechanism, it would seem to be the result of torsion. 

In other cases it seems to be caused by the effort of throwing a 
stone, a snow-ball, or some other projectile. There have been a 
good many such instances, at all periods of life except old age. 
M. Baffos saw the humerus broken in this way in a young child; 
Chevalier, in a young man of seventeen; Dupuytren, at twenty- 
three; Jacquemin, at thirty-one; Bottentuit, Nicod and Guthrie, in 

* Debeaumarchef, Journal de Med. de S6dillot, tome xxii, p. 384 ; Caffort, 
Arch. G&a. de Medecine, tome xv, p. 130. 



430 A TREATISE ON FRACTURES. 

adults. 511 Double has given a quite ingenious theory as to these 
fractures; he attributes them to the projectile force given to the 
lower part of the arm, while the deltoid holds back the upper por- 
tion; just 'as we break a stick bj holding it firmly by one end and 
violently beating the air with the other.f If this be so, the humerus 
should give way below the insertion of the deltoid; now in Botten- 
tuit's and Dupuytren's cases, the fracture was seated near the junc- 
tion of the middle and lower thirds of the bone ; Nicod saw it a little 
above the middle, and Chevalier, Jacquemin and Guthrie saw it just 
at the insertion of the deltoid. The theory of Double is therefore 
quite sustained by experience; the fracture seems due here to forci- 
ble flexion of the bone. 

Other movements and efforts may likewise result in fracture of the 
humerus. Manne relates the case of a soldier who broke it at .the 
lower part in trying to throw a ball to a great distance ; and Seaton 
saw the same thing in a man of forty-six who had tried to knock 
back a tennis -ball. { In a case cited by Lonsdale, the cause was a 
blow which the patient gave with his fist; the bone was broken at 
the junction of the middle and lower third. A man slipping, and 
trying to keep up, stretched out his hand against a wall which was 
close by; the humerus gave way near the insertion of the deltoid. 
Another broke his at the same point by putting out his arm between 
two persons to separate them.§ Probably in these different cases 
the mechanism was very much the same as that pointed out by 
Double. Since however the fracture may take place at very various 
points, we must recall what was elsewhere shown, viz., that most 
generally these almost spontaneous fractures are preceded by a sub- 
inflammation of a circumscribed portion of the bone, which is thus 
disposed to give way. It would otherwise be especially difficult to 
comprehend the case related by Liston of a woman, who broke the 
humerus by stretching out her arm to seize a child with which she 
was playing; and a similar case in which the fracture resulted from 
a slight effort in lifting a basket of grapes. M. Goyrand expressly 
states that the patient had long been subject to severe and deep- 
seated pains in the arm.|| 

* Baffos, Archiv. Gin. de Me'decine,- tome xxi, p. 449 ; Chevalier, Journal 
de Boyer, tome xx, p. 276 ; Dupuytren, Gazette des Hopitaux, 1833, p. 29 ; 
Jacquemin, Recueil de Memoir es de Me'decine, Chir., et Ph. Militaires, tome 
vii, p. 245 ; Bottentuit, Journal de SSdillot, tome xxiv, p. 375 ; Nicod, Annuaire 
des Hopitaux, 1819, p. 496 ; Guthrie, American Journal, August, 1835, p. 524. 

f Journal de Sidillot, tome xxiv, p. 376. 

% Manne, Journal de Sidillot, tome xxiii, p. 265 ; Seaton, American Journal, 
Feb., 1836, p. 512. 

\ Kuttinger, Recueil de M6m. de Mid., Cliir., et Ph. Militaires, tome viii, 
p. 258. 

|| Liston, American Journal, Nov., 1836, p. 249 ; Goyrand, Gazette des Ho- 
pitaux, 1836, p. 477. 



A TREATISE ON FRACTURES. 431 

Aii entirely different mechanism must be admitted, however, for 
the singular case briefly reported by Larrey to the Academie de 
Medecine. A lady alighting from a carriage, and feeling the step 
give way beneath -her, grasped strongly the handle of the coach- 
door ; the humerus was thus fractured just above the deltoid.* 
It would seem that here the deltoid tended to draw up the lower por- 
tion of the bone, while its upper portion was drawn downward by the 
pectoralis major, teres major, and latissimus dorsi. 

Lastly, Yoleainer has related an instance of this fracture in a boy 
of ten, from muscular contraction during an epileptic fit ; but per- 
haps this observation is not perfectly satisfactory, f 

Aside from these special causes affecting certain points, the hume- 
rus may be fractured anywhere in its extent. Sometimes the frac- 
ture is incomplete, as Jurine and Hart would seem to have observed 
it ; but this is very rarely the case. More commonly the fracture is 
serrated, without any great injury to the periosteum ; and the frac- 
ments, mutually interlocked, cannot be moved upon one another, and 
hence give no crepitation. Raleigh saw a fracture of this kind in a 
child nine years old, which had fallen out of bed ; for eight days no 
sign of fracture was detected by the surgeon ; on the ninth, perceiv- 
ing that the humerus bent toward its middle, he diagnosed an incom- 
plete fracture. \ I have seen an entirely similar case in a child of 
fifteen months, and another in a girl of fourteen years ; the fracture 
is quite complete, but it gives hardly any sign of its existence except 
this unnatural flexibility of the bone. 

It is to be remarked that in most fractures from muscular action, 
the fragments remain in contact, without any displacement. Du- 
puytren's patient forms, however, a remarkable exception to this 
rule ; in his case the fragments were entirely disjoined, and so mova- 
ble that consolidation could not be obtained ; resection had to be 
performed three months afterwards. 

But in fractures from ordinary causes, it is far more common to 
ineet with more or less considerable displacements, varying according 
to the direction of the blow, and especially to that of the fracture. 
Fig. 35 represents a double fracture ; the upper fragment is dis- 
placed outward from the middle one, and this again in front of the 
lower one. The section of the same specimen, Fig. 36, shows at 
once these displacements and the overlapping consequent upon them. 
Fig. 37 represents a simple fracture, with a splinter detached from 
the anterior wall of the bone. The two ends of this wall have been 
replaced in contact, and yet the lower fragment projects notably 
backward and upward ; this is due to the formation by the two frag- 
ments of an angle opening anteriorly. Fig. 38 shows a fracture 

* Archiv. G6n. de MMecine, tome xv, p. 130. 
t Ephem. Nat. Curios., decade i, an ii, obs. 225. 
% American Journal, Feb., 1836, p. 512. 



432 A TREATISE ON FRACTURES. 

running obliquely downward, inward and forward; the displacement 
lias occurred in the same direction. Fig. 39 shows a fracture ob- 
liquely downward and inward; the displacement is in the same direc- 
tion, but here there is moreover an angle opening internally. Fi- 
nally, in Fig. 40 we see a fracture downward and backward ; the 
lower fragment rides up in front of the other, with which it forms 
a very marked angle anteriorly. 

I might multiply these examples ; but it suffices to examine the 
specimens displayed in our museums, to perceive that these displace- 
ments are governed by no general law, except that of the direction 
of the fracture. When the fracture is nearly transverse, and com- 
minuted ; when the injury done to the soft parts has destroyed nearly 
all connection between the fragments, then only can these latter 
yield to the muscles acting upon them ; and the deltoid tends to raise 
outward the fragment into which it is inserted. But in most cases 
the action of the muscles is limited to the production and mainte- 
nance of overlapping. 

To the causes already enumerated must, however, be added one 
more, of too great importance to be passed over, viz., improper 
treatment ; to this are chiefly due angular deformities forward, in- 
ward or backward. 

The phenomena of fractures of the humerus are par excellence 
those of fractures of the long bones ; pain, loss of power in the arm, 
bending of the bone, mobility of the fragments in various directions ; 
prominences, deformity and shortening, resulting from the different 
displacements ; and lastly, crepitation. In general, serrated frac- 
tures without displacement do not give rise to any appreciable amount 
of swelling ; I would, however, remark that in one of the cases re- 
sulting from throwing a stone, that of Guthrie, the arm was attacked 
by phlegmonous inflammation and suppuration. In another case of 
the same kind, that of Nicod, an abscess formed at the seat of frac- 
ture, after more than fifty days, and when the callus was already 
consolidated ; some small splinters escaped, and after that the cure 
was rapid and complete. 

But when the external violence has been severe enough to disjoin 
the fragments, there is no other fracture which is so often followed 
by inflammatory swelling as that of the humerus ; and the imminent 
danger of this complication should constantly engage the attention 
of the surgeon. 

The diagnosis offers no serious difficulty as to the fracture itself; 
but the swelling very often makes it impossible to determine exactly 
the extent, or even the direction of the displacement. 

The prognosis is by no means grave when the fracture is simple, 
and without displacement ; twenty-five or thirty days suffice for con- 
solidation in young subjects, and in adults, from thirty-five to forty 
days. When the displacement occurs only in the thickness of the 



A TREATISE ON FRACTURES. I 433 

bone, it may be easily overcome, and all will go on well. But when 
there is great obliquity and overlapping, or a splintered or multiple 
fracture, some deformity is inevitable, and the callus will be a week 
or two longer in forming. Along with inflammation comes the dan- 
ger of suppuration, and of subsequent stiffening of the joints, which 
it is hard to remedy. Finally, it should not be forgotten that of all 
fractures, those of the humerus are most liable to non-union. 

Reduction should be made in the same position in which the in- 
jured limb is to be kept. If the patient can sit up without inconve- 
nience, the forearm should be flexed at a right angle, in front of the 
chest, the elbow close to the body ; if circumstances require him to keep 
his bed, the forearm should be laid upon cushions, and hence a some- 
what obtuse angle will be better. One assistant raises the forearm 
and hand ; another grasps the shoulder with both hands, to make 
counter-extension ; a third draws down the flexed forearm or the 
condyles of the humerus, to make extension ; while the surgeon, 
standing on the outer side, attempts coaptation. First of all we 
must be assured that the epicondyle is in the same line with the inser- 
tion of the deltoid, and with the most prominent part of the shoulder ; 
and then that the arm has regained its natural form, length, and 
thickness ; but I cannot sufficiently warn the young surgeon that 
simple as may be the displacement, the coaptation will never be ab- 
solutely perfect. 

All sorts of apparatuses have been tried in these fractures; splints, 
immovable and plaster apparatuses, cuirasses, cushions, boards, troughs, 
and contrivances for making permanent extension. In studying the 
indications followed, we see that at first, the mere keeping in contact 
of the two fragments was aimed at, without any attempt at fixing 
firmly the articulations above and below; such is the object of the 
ordinary splints. 

Afterwards such immobility was sought for the elbow, as in Ames- 
bury's and the immovable apparatus. 

Then the immobility was extended to the shoulder, as in the appa- 
ratus of M. Bonnet, of Lyons. 

Then overlapping was combated by means of permanent extension. 

And finally, in compound fractures, facility of dressing has been 
provided for in the hyponarthecic apparatus. 

The ordinary splints date back as far as Hippocrates ; I shall 
merely describe Boyer's method of applying them. First, even be- 
fore making any attempt at reduction, he enveloped with a roller the 
hand and forearm ; then, the reduction being made, either with the 
same bandage or with another he covered up the arm from below up- 
ward, carefully filling the hollow at the insertion of the deltoid with 
charpie or cotton, and making three or four circular turns just over 
the fracture. This done, he surrounded the limb with three or four 
splints, according to its size. When four splints seemed requisite, 

28 



434 A TREATISE ON FRACTURES. 

one was put on the outside, one on the inside, one in front, and one 
behind, their length being adapted to that of the different sides of 
the arm ; When three answered the purpose, the inside one was left 
off. These splints were made either of thin slips of wood, or of tin ; 
for young subjects, even of mere pasteboard. They were held in place 
by an assistant, until fastened by turns of a bandage, with which the 
arm was completely enveloped. The arm was then fastened to the side, 
the forearm being held in a sling; and circular turns were made to 
surround the trunk and arm together, so as to render the arm en- 
tirely immovable. 

Some modern surgeons postpone bandaging the forearm until after 
reduction, and put no circular turns over the sling. Boyer's plan 
was better calculated to preserve the coaptation ; and he remarks 
very justly that if we employ the sling only, the wrist and fore- 
arm may be carried backward and forward, thus giving the lower 
fragment a rotary movement. However, even with this precaution, 
Eoyer could not prevent some slight flexion of the elbow; Amesbury 
sought to guard against this. 

Amesbury's apparatus was composed of (1) two beech-wood splints 
fixed firmly at a right angle, so as to fit the anterior face of the arm 
and the superior face of the forearm; (2) of another beech-wood 
splint merely covering ,the posterior face of the arm down as far as 
the elbow ; (3) of two common deal splints for the sides of the arm ; 
the whole to be fastened together by means of five straps with 
buckles. He commenced, like Boyer, by enveloping the limb with a 
roller, from the wrist up to the shoulder ; he carefully padded each 
splint ; and lastly, he supported. the forearm in a sling. 

The immovable apparatuses attain the same end with less trouble. 
The simplest is doubtless that of M. Velpeau. A piece of dry linen 
being first spread over the skin, a dextrinated roller is applied from 
the hand up to the shoulder, and fixed above by a few turns of the 
spica over the shoulder. Commonly two or three layers of the dex- 
trinated bandage are sufficient ; it is only in exceptional cases that 
M. Velpeau adds two sheets of pasteboard, or graduated compresses. 
This dressing would seem calculated to make the shoulder perfectly 
immovable; but not so efficiently as the cuirasse of M. Bonnet, of 
Lyons. 

This is made of a cuirass covering half the chest, before and be- 
hind, to which is attached a splint, hollow anteriorly, directed down- 
ward and outward so as to receive the arm, and continuous with an- 
other one which is horizontal, for the forearm and hand. The basis 
of this apparatus is iron wire, making it at once firm and light ; but 
it is carefully padded, and covered with chamois-leather. The upper 
splint, hollowed in front to receive the arm, is fastened by circular 
straps ; so that the fracture may be examined, and the pressure in- 
creased or lessened, without disturbing the arm at all ; and as this 



A TREATISE OX FRACTURES. 435 

splint is a mere appendage of the one around the chest, all the pa- 
tient's movements are movements in totality, and he can sit up, rise, 
etc., "without the motions of the trunk occasioning the slightest dis- 
placement in the fracture.* 

Let us test this in the simplest fractures, without overlapping, in- 
flammation, or external wound. In such a condition of things, 
unless there is excessive mobility of the fragments, the body-piece 
proposed by M. Bonnet may seem superfluous ; Amesbury's appara- 
tus, in spite of its complication, does not insure perfect immobility ; 
and that of M. Velpeau, although very simple, has the inconvenience 
of concealing the parts. Therefore I would in ordinary cases prefer 
common splints ; even Boyer's apparatus might, it seems to me, be 
brought into a much simpler form. 

I have elsewhere mentioned (p. 170 et seq.) what should be thought 
of the roller improperly applied over the hand and forearm. I limit 
my application of the bandage and splints to the arm itself; when 
there is danger of swelling and inflammation, I leave off the roller 
entirely, and apply the splints to the skin, only with compresses of 
equal width beneath them. These splints, confined by means of two 
or three strips of diachylon, do not tend to become deranged, and 
their interspaces enable me to keep the state of the limb always in 
view. 

For the rest, the sling suffices to support the forearm when the 
fracture is without displacement ; otherwise the arm must be more 
firmly fastened to the body. But with the circular turns used by 
Boyer, or with the ordinary body-bandage, there is one danger to 
which attention has not been called. In the healthy state, when the 
forearm is applied to the chest, the epitrochlea remains separated 
from the trunk ; and if in case of fracture our circular turns tend to 
bring the two together, they can only succeed by making the two 
fragments form a more or less marked angle. Hippocrates would 
seem to have had this in view when he recommended putting a thick 
linen compress between the elbow and the ribs. I cannot rest satis- 
fied with this, but employ a quilted cushion, thicker below than above, 
and reaching from the armpit to the elbow, so as at once to afford 
the arm a more equable support than the ribs would, and to keep 
the epitrochlea apart from the body. However tractable the dis- 
placement may be, I. substitute for the sling a hollow pasteboard 
splint to support the forearm and hand, embracing also the lower 
portion of the arm. 

Other difficulties present themselves when there is overlapping to a 
greater or less degree. J. L. Petit advises us then to tie the sling 
more loosely, so as to allow the arm to hang a little, hoping in this 
way to counterpoise the muscular contraction ; but the weight is too 

* Bulletin de Tlifrrapeutique, tome xviii, p. 180. 



436 A TREATISE ON FRACTURES. 

small to hare such an effect. M. Petrequin told me lie had tried 
Suspending a weight to the forearm during the day, and during the 
night replacing it by two loops, one in the axilla and the other at 
the elbow, fastened respectively to the head and foot of the bed. 
M. Bonnet would attain the same end with his cuirass, drawing the 
whole down by means of thigh-pieces; but he has omitted to say how 
he would make his counter-extension. Finally, I have described, in 
connection with fractures of the cervix humeri, the contrivances of 
MM. Coillot and Gely, which may be as properly applied in fractures 
of the shaft ; there remains to be mentioned the one devised by 
Lonsdale. 

This is an iron splint about four centimetres in width, long enough 
to reach from the axilla to below the elbow. Its lower end curves 
under the elbow, as if to embrace it, and ends in a sort of hook to 
give attachment to a bandage ; for the same purpose the body of the 
splint presents two small lateral projections opposite to and at the 
same level with this hook. The other end of the splint has a crutch- 
head, movable up and down, and fixed at the required height by a 
screw. This crutch-head being put in the axilla, the elbow engaged 
in the curve below and kept there by a bandage fastened as before 
mentioned, extension is made by drawing one way on the elbow, and 
the other on the crutch-head ; when the arm regains its natural 
length, the only thing to be done is to fasten the screw. It is unne- 
cessary to say that we must very carefully protect the parts pressed 
upon, in order to prevent sloughing. 

[The plan generally adopted in Philadelphia is the same as that 
mentioned for fractures of the cervix ; except that the pasteboard 
cap is here useless, unless it be to better confine the shoulder; but 
at any rate it is well to apply a pasteboard splint on the outside of 
the arm. The advantage of the inside angular splint, which should 
extend well up into the axilla, is that we have along the inside of the 
arm a fair chance at the bone, which is there almost subcutaneous. 
Very excellent results have followed this mode of treatment.] 

I have nothing to add touching the choice of these various methods. 
The surgeon should never forget that permanent extension is always 
dangerous, and needs great caution and watchfulness in its application. 

When the fracture is attended with high inflammation, or when it 
is compound, the patient should be put to bed, and the injured limb 
supported on cushions, the forearm at an obtuse angle with the arm ; 
the elbow should be on a level with the shoulder, the hand a little 
higher than the elbow. No bandage should be applied, but support 
may be given by means of two lateral splints. We must then en- 
join upon the patient great quietness, in order that the upper frag- 
ment may be undisturbed by any movements of the head, trunk, or 
shoulder. To insure this is very difficult; hence consolidation is often 
greatly retarded, especially when an external wound communicates 



A TREATISE ON FRACTURES. 437 

with the seat of fracture. It is in cases of this kind that the cui- 
rasse of M. Bonnet has seemed to me to be of great use, after the 
subsidence of the inflammatory symptoms. 

"When consolidation is long delayed, we must not forget, while fix- 
ing the fragments as firmly as possible, to make passive motion of 
the shoulder, and particularly of the elbow-joint. [Dr. Christopher 
Johnston, of Baltimore, recently informed me that in 1852, while 
following Langenbeck's practice in Berlin, he saw an instrument 
used by Professor L. in a case of delayed union after fracture of 
the humerus, acting on the same principle as that devised by M. Mal- 
gaigne for fractures of the patella; the result was favorable.] As to 
articular stiffening, and other consecutive symptoms, I refer the 
reader to the remarks made in connection with fractures generally. 



§ IV. — Fractures of the Humerus above the Condyles. 

I give this name to what Dupuytren called fracture of the lower 
extremity of the humerus,* in order to make our language more 
precise. It is, then, a solution of continuity, separating the whole 
articular extremity of the bone, without entering the joint ; and in 
children, who are more subject to it than adults are, it is probably 
in many cases a disjunction of the epiphysis. I have elsewhere men- 
tioned M. Champion's case, in which this idea was confirmed by the 
autopsy, (see pp. 70 and 72.) 

Most commonly this lesion is the result of a fall on the elbow ; 
although in M. Champion's patient it was caused by traction, the 
forearm having been caught in a carding-machine. 

The symptoms are in the first place those of all fractures: pain, 
loss of power, swelling, crepitation, etc. Sometimes there is no dis- 
placement ; the fracture is then discovered by the crepitation, which 
is especially elicited by twisting the forearm upon the arm. Another 
good plan is to try to bend the humerus backward, so as to make 
the two fragments form an angle salient anteriorly. 

When the fragments are displaced, they generally form this very 
angle ; the upper one remains in place, the lower one following the 
movement of the olecranon, w T hich is drawn upward and backward 
by the triceps. Hence the antero-posterior diameter of the elbow 
is increased ; a transverse prominence in front is due to the angle at 
the seat of fracture ; the olecranon projects backward sometimes 
four or five centimetres more than that of the sound side, and passes 
up also along the posterior face of the arm; in a word, we have 
nearly all the phenomena of luxation backward. Hence mistakes 
have more than once been made, and the differential diagnosis de- 
mands particular attention. 

*See Lecons Orales, tome i, p. 117; and the Gazette Medicate, 1833, p. 102. 



438 A TREATISE ON FRACTURES. 

What is the real direction of the fracture? Sir A. Cooper main- 
tains that it is oblique; Dupuytren considers it transverse; and in a 
girl of fifteen, who died after receiving such an injury, it was clearly 
made out that both fragments contributed to the angle. In the case in 
which M. Champion made an autopsy, the age being at least thirteen, 
there had been separation of the epiphysis and detachment of a thin 
splinter of the diaphysis, which is almost equivalent to a transverse 
fracture. But in a specimen in the Musee Dupuytren, which mani- 
festly came from an adult, we may see, in spite of the solidity of the 
callus, that the fracture was oblique downward and backward. Fig. 
40 gives a very correct idea of the displacement. Lastly, I have 
seen in a little girl two years old a fracture above the condyles, of 
several months' standing, in which the fragments were extremely 
movable, forbidding all hope of union ; the fracture was oblique from 
one side to the other, running from without inward. 

To sum up, here as elsewhere, the fracture may be transverse, 
oblique from before backward, or oblique from one side to the other; 
it may exist without displacement, or may present any displacement 
whatever. Thus in the Muse'e Dupuytren there is a specimen (No. 
88) of a fracture of this kind united with an angle posteriorly. 
When the fragments are completely disjoined, they no longer form 
an angle, but may overlap or twist upon one another; M. Guersant 
mentions a rotary displacement of the lower fragment, by which the 
epitrochlea was brought in front.* In the specimen represented in 
Fig. 41, to which I shall again refer in speaking of fracture of both 
condyles, the upper fragment descended behind the other. 

Such rotation or overlapping must add to our means of diagnosis. 
But this is an affair of more difficulty when the injury simulates a 
luxation backward. Sir A. Cooper, who was the first to treat of the 
differential diagnosis, recommends us in the first place to try if we can 
detect any crepitation; and he adds that in fracture all the pheno- 
mena disappear when traction is made on the forearm, but only to 
reappear when this is suspended; while a luxation, when once re- 
duced, does not recur. Dupuytren has given different directions. 
Grasp, says he, one fragment in each hand, the thumbs in front and 
over the fracture, and attempt thus to make reduction. This simple 
manoeuvre, without any other extension, is generally sufficient, espe- 
cially when the injury does not date back more than twenty-four or 
thirty-six hours. But the reduction being thus completely performed, 
push the forearm backward again; if it was a luxation, the reduc- 
tion will be persistent ; if there is a fracture, the displacement will 
immediately reappear. 

These means are doubtless useful, but will not suffice in all cases. 
The swelling of the soft parts may render the crepitation very indis- 

* Gazette des Hopttaux, 1845, p. 519. 



A TREATISE ON FRACTURES. 439 

tinct, or even mask it completely. The reappearance of the displace- 
ment may occur as well in luxation with fracture of the coronoid 
process as in fracture of the condyles. I long ago pointed out symp- 
toms far more strictly conclusive.* Whatever may be the projection 
backward of the olecranon, it is never any farther from the epcon- 
dyle and epitrochlea than in the natural condition, if the case is one 
of fracture; it is much more so if there is a luxation. So also, in 
fracture the anterior prominence is narrower and more rounded than 
in luxation; but moreover, it is here above the fold of the elbow, 
while in luxation it is far below it. Once more, on measuring the 
distance from the acromion to the epitrochlea, we find in the fracture 
a shortening which does not occur in the luxation. 

The prognosis is not without gravity. I do not allude to the 
symptoms which may supervene, although Monteggia saw a simple 
fracture of this kind give rise to tetanus, which not even amputation 
could prevent from terminating fatally. This instance is probably 
unique, and does not show what we usually have to dread. But the 
swelling may be so great as to hinder reduction, and thus compromise 
the play of the elbow-joint; the mere maintenance of reduction is not 
easy ; so that, as Sir Astley Cooper remarks, even after the most 
skilful treatment, the motions sometimes remain extremely impaired; 
and if the accident has been misunderstood or badly treated, the de- 
formity and loss of motion may be very considerable. Lastly we 
must not lose sight of the danger of non-union, as in the child 
recently mentioned. 

Reduction is performed as stated, either by drawing down the 
forearm, or by pushing back the angle salient anteriorly with the 
two thumbs, while the other fingers of the right hand, for instance, 
bring the olecranon downward and forward ; but when the reduction 
is intended to be permanent, it is proper to make it in the position in 
which the limb is to be kept. 

The position almost universally adopted in these cases since the 
time of Hippocrates, is semiflexion of the forearm. Boyer says 
however that certain surgeons, whom he does not name, proposed to 
extend the limb, fixing it with four splints. He thinks that this 
may be the most solid mode of doing up the fracture; but as such a 
position would soon become insupportably painful, and as, besides, 
anchylosis occurring with the arm straight would be particularly in- 
convenient, he concludes by giving the preference to semiflexion. I 
would not be so exclusive; and if mere extension would keep the 
fragments in place in a case of some difficulty, I would not hesitate 
to resort to it, at least in the early stages, using, however, all the 
necessary precautions against anchylosis. 

But if reduction can be made as well in the semiflexed position, 

* Gazette Medicate, 1834, p. 103. 



440 A TREATISE ON FRACTURES. 

this ifl certainly preferable. Henckel kept the arm fixed thus by 
means of two lateral angular splints. Boyer commenced by the 
application of a roller to the limb; after which he fitted over its 
whole length two splints of thick pasteboard, one on the surface of 
flexion and the other on that of extension, bent so as to suit the bend 
of the limb; these were notched to the extent of one-quarter of their 
width on each side, opposite the elbow, so as to fit better, and moist- 
ened so as to take the exact form of the limb. They were kept in 
place by a bandage long enough to cover the whole limb twice. 

Sir Astley Cooper's apparatus was somewhat different. After the 
roller, he placed behind the limb a splint bent at a right angle, to 
maintain it in this position; then a small straight splint over the an- 
terior face of the arm merely, the whole being confined by bands. It 
appears that Sir A. Cooper had in view, with his small splint, an 
indication overlooked by Boyer, and that he thus sought to press 
backward the angle of the two fragments. This however was not 
sufficient; the olecranon requires at the same time to be pressed 
forward. This was the double object proposed by Dupuytren. 

Dupuytren therefore applied over the whole anterior surface of 
the arm graduated compresses, made somewhat thicker opposite the 
prominence of the fragments; other compresses were arranged pos- 
teriorly ; over these were placed two splints, one anterior, pressing 
upon the prominence, and the other posterior, bearing on the ole- 
cranon and pushing it forward. With the same object there was 
added another compress placed transversely, its middle over the 
olecranon and its two ends crossed in front of the arm ; the whole 
was kept in place by a roller. 

Henckel's apparatus, or that of Boyer, will answer when there is 
no displacement, or when the displacement, once reduced, shows no 
tendency to recur. But w T hen we have to strive against this disposi- 
tion of the two fragments to form an angle anteriorly, we need some- 
thing which will act more directly; and neither Sir Astley Cooper's 
anterior splint, nor Dupuytren's graduated compresses, are sufficient. 
I place then across the anterior face of the arm a pad two or three 
fingers'-breadths long, made by a compress of from eight to sixteen 
folds; over this pad the lower end of the anterior splint presses to 
much greater advantage. For a posterior splint, that of Sir A. Cooper 
would doubtless be the best if it were at hand, since it keeps the 
limb most at rest; and if we can command only an ordinary splint, 
we may supply its place by fitting to the arm and forearm a paste- 
board trough fastened with bands. The roller beneath the splints is 
useless; and Dupuytren's transverse compress over the olecranon 
could act only momentarily. It is in the pressure on the two splints 
that the efficiency of the entire apparatus resides. I prefer to all 
other means strips of adhesive plaster, as less likely to become re- 
laxed; one of these strips, surrounding the lower end of the posterior 



A TREATISE OX FRACTURES. 441 

splint, should have its ends crossed over the anterior one, so as to 
insure steady pressure over the olecranon. 

[An excellent mode of treatment for all fractures of the humerus 
near its lower extremity, consists in the use of an angular wooden splint 
bandaged to the front of the arm and forearm; this should reach up 
to the shoulder and down to the ends of the fingers, so as to render 
the entire member immovable; the surface applied to the limb should 
be hollowed out and well padded, and if necessary a posterior splint 
of pasteboard may be so arranged as to aid materially in keeping the 
fragments in place. It is very important, in order to obviate stiffen- 
ing of the joint, that the angle of the elbow should be varied from 
time to time; and this may be done either by providing a supply of 
splints of different angles, or by constructing one with a hinge be- 
tween its two portions, so as to change the angle at will; a Stro- 
meyer's screw being employed to maintain it at the desired degree. 
It is not necessary, perhaps not even desirable, that a bandage should 
be first applied to the injured member.] 

The apparatus should not be removed unless some urgent symptom 
should arise; Dupuytren kept it on for a month. Delamotte relates 
one case of complete consolidation, in a boy ten years old, at the end 
of three weeks. * There would be some advantage, and no incon- 
venience, in leaving the dressing in place for the whole time advised 
by Dupuytren, on condition of observing another precept, laid down 
by Sir A. Cooper; namely, that at the end of fifteen days in young 
subjects, or of three weeks in adults, passive motion of the elbow 
should be cautiously commenced, so as to prevent anchylosis. 

If we have an intractable child to treat, it would be well to follow 
Delamotte's plan of posting two servants by the patient night and 
day. to prevent any injurious movement ; a precaution which would 
doubtless have no small influence on the rapidity and regularity of 
consolidation. 

When a fracture of this kind has united badly, all we can do is 
to restore the motions of the elbow, either by exercise or by some 
mechanical contrivance. 



§ V. — Fractures of the Ujjitrochlea.f 

The history of these fractures is only of very recent date ; the 
first work on the subject was only published in 1818. J They con- 
sist in a breaking off of the epitrochlea either at its point or at its 
base, but without at all involving the articular surface. 

* Delamotte, J . obs. 352. 

t [The internal condyle of American and English anatomists.] 
X B. Granger, On a /' 'are of the Inner Condyle of the 

and Surgical Journal, vol. xiv, p. 196. 



442 A TREATISE ON FRACTURES. 

Although the epitrochlea is much more elongated in adult age 
than in early life, it is almost always in children that we see it 
broken. (J ranger reports two instances observed in boys eight and 
eleven years old; M. Pezerat saw two others, one in a boy of 
twelve, and the other in a young man ;* I have myself had occasion 
to treat such a fracture in a boy of ten. There is therefore ground 
for supposing that in some cases at least it is a disjunction of the 
epiphysis; the epitrochlea, as is w T ell known, ossifying separately 
until about the age of seven years. Still this preference, as it were, 
for young persons, is not exclusive, and I have seen one instance 
occurring in a man of fifty-two. 

The most common cause would seem to be a fall on the epitro- 
chlea, the elbow being separated from the body; this was the case 
in M. Pe'zerat's two patients, and in my own ; and this was especially 
clear in my little boy, whose elbow was driven into the gravel, leav- 
ing an impression there. Granger, however, does not admit this 
view of the mechanism ; he thinks the fracture is the result of violent 
contraction of the muscles attached about the epitrochlea, as for in- 
stance when the arm is put out in falling, and the hand, touching the 
ground first, receives the whole weight of the body; in support of 
this theory he relates a case in which the patient, a child eight years 
old, said he had fallen on his hand. He has also seen this fracture 
complicated, once with a luxation of the radius, another time with a 
luxation of the elbow, and as these luxations, says he, are known to 
be produced by falls on the hand, the fracture of the epitrochlea 
should be referred to the same cause. This argument is essentially 
defective in its foundation; for, as I shall show at the proper time 
and place, most luxations of the elbow result from falls on the elbow 
itself. I do not deny that the epitrochlea may be torn off by the 
action of the muscles, and as a consequence of falling on the hand; 
but this must be very rare, and would need to be determined with 
much greater precision. 

The symptoms vary in this as in all other fractures. In my little 
patient, the pain and swelling made me suspect the fracture; but the 
mobility was doubtful, and no crepitation w r as perceptible; it was 
not until eight clays afterwards, when the swelling had subsided, that 
all doubt was removed by the occurrence of distinct crepitation. 
There was no appreciable displacement. In the man of fifty-two, 
before mentioned, the epitrochlea had been drawn downward to 
nearly the level of the articular surfaces; the muscles attached to it 
were somewhat in relief beneath the skin; the forearm remained 
flexed upon the arm and pronated; extension was very painful, and 
supination still more so, so that in fact it could not be completely 

* P6zerat, Obs. surlafract. de V 6pitrochl6e; Journal CompUmentaire, tome 
xlii, p. 418. 



A TREATISE ON FRACTURES. 443 

made. In the movements of flexion and extension of the forearm, 
the hand placed on the epitrochlea felt a sensible crepitation; this 
apophysis could moreover be grasped separately and moved back- 
ward and forward. 

It appears that displacement is most commonly present; it existed 
in both M. Pezerat's cases, and Granger notes it as constant. If 
so, the epitrochlea is always carried downward; but Granger adds 
that sometimes its position varies, it being found now in contact with 
the olecranon, and again an inch or even more in front of it. 

Granger saw also in one or two cases ecchymosis extending along 
the inner border of the forearm, which would seem to me a plain in- 
dication of a direct blow upon this part. Neither M. Pezerat nor 
myself have met with anything but very moderate pain and swell- 
ing. Granger was less fortunate; it appears that in all his cases he 
had to combat very high inflammation of the elbow and forearm, 
extending to the termination of the fleshy fibres of the muscles at- 
tached to the epitrochlea, and inducing such swelling as almost 
entirely to prevent the motions of the elbow. 

Such inflammation could hardly result from anything but the ex- 
treme violence of the cause of the fracture ; and the displacement, 
kept up by the muscular irritation, would then resist all our efforts 
at reduction. Hence there is deformity, not produced merely by 
the drawing down of the fragment, but also and chiefly by the 
shrinking of the muscles attached to it. The inflammation of the 
elbow inevitably brings on also most obstinate stiffening of the joint, 
to such a degree that in the first case he examined, Granger feared 
for some time that incurable anchylosis would ensue. Lastly the 
ulnar nerve, passing between the olecranon and the epitrochlea, is 
also sometimes injured, either, as I think, by the direct blow, or ac- 
cording to Granger's view, by the pressure to which it is subjected 
in the displacement of the epitrochlea. He cites a remarkable case 
of this. 

It was in the child eight years old, who said he had fallen on his 
hand. The inflammation was violent, the stiffness of the elbow ob- 
stinate ; still, in less than three months after the accident the child 
had recovered the free and complete use of the joint, but the ulnar 
nerve remained paralysed. From the moment of the injury, the 
little finger, the ulnar side of the ring-finger, and the integuments 
of the ulnar side of the hand, had lost all sensation. The abductor 
of the little finger, and the two adjacent muscles (the short flexor and 
the adductor) were paralysed. Some weeks after the accident, an 
eruption of small vesicles appeared on the little finger and ulnar 
edge of the hand, and lasted two or three months. In the course 
of a few years, exercise restored gradually not only the muscular 
power, but also the sensibility of the skin; and at the end of seven- 
teen years there remained only some uneasiness after excessive use 



444 A TREATISE ON FRACTURES. 

of the arm at the point where the displaced fragment had become 
adherent, and temporary numbness of the little finger when it was 
strongly compressed. 

Granger observed the same phenomena, namely the paralysis and 
the vesicular eruption, following the same fracture in two other 
patients. 

The diagnosis is easy, except when the swelling prevents us from 
grasping and moving the detached fragment. 

The prognosis is very favorable as regards the fracture itself; if 
there is little or no displacement, consolidation occurs regularly in 
twenty-five or thirty days; if the displacement is considerable and 
cannot be reduced, there is involved merely a slight deformity and a 
temporary hindrance to the play of the muscles of the forearm. But 
it must be recollected that stiffening of the joint is almost inevitable; 
in my little patient, notwithstanding the slight grade of the inflam- 
mation, the angle of the elbow could only be varied between 80° 
and 140° after two months and a half had elapsed. 

As to treatment, Granger merely kept the forearm in the semi- 
flexed position, rejecting all apparatus as not only useless, but hurt- 
ful by preventing the continual exercising of the joint, which in his 
opinion constitutes one of the principal indications. Pezerat pre- 
fers strong extension, with the view of relaxing the extensor mus- 
cles. This is an anatomical error, since it is the flexors which are 
attached to the epitrochlea, and hence there is a real advantage in 
flexing not only the forearm, but also the hand and fingers. If this 
position does not suffice to restore the detached fragment to its place, 
I doubt if any apparatus could keep it there; however there might 
be some advantage in trying it, if we only came somewhere near our 
aim; and if there be any displacement forward or backward, as has 
been seen by Granger, it would be easy to remedy it. I think also, 
notwithstanding his views, that it is important to insure consolida- 
tion, without however overlooking the danger of anchylosis. In the 
two cases I had occasion to treat, the forearm being semiflexed, I 
placed in front of the epitrochlea several pieces of agaric, with the 
double object of protecting it from pressure and pushing it back- 
ward; I surrounded the elbow with a dextrinated bandage, and 
being careful to move the joint at about the fifteenth or twentieth 
day, I obtained in both cases regular consolidation, without much 
stiffening. Granger himself declares that of five patients treated 
by him four recovered completely the motions of the elbow; and if 
the fifth lost them somewhat, it was because his fracture had been 
complicated with luxation. 



CHAPTER XII. 

FRACTURES OF THE ELBOW. 

I give this name to all fractures which pass into the articulation. 
I shall treat in succession: (1) of fracture of both condyles of the 
humerus ; (2) of fracture of the external condyle ; (3) of fracture of 
the trochlea or inner condyle; (4) of fracture of the olecranon; 
(5) of comminuted fracture of the elbow. Fracture of the coronoid 
process is generally attended with luxation of the ulna, and I shall 
postpone its consideration until I come to treat of that luxation. 

§ I. — Fractures of both Condyles of the Humerus. 

It was, if I mistake not, Desault who first called attention to this 
fracture, which would seem a very rare one; for up to the present 
time I have only been able to collect eight cases, four simple, and 
four with the complication of an external wound.* It is a combina- 
tion of a fracture above the condyles with another running more or 
less vertically, separating the two condyles and thus making three 
fragments. 

The only cause alleged is a fall on the elbow, this being sometimes 
close to the body, and sometimes apart from it. This fracture has 
been observed both in men and in women; the age of the patients 
has varied from eighteen to forty- one years. Its seat is not always 
the same. In a case communicated by Ivimy to Sir A. Cooper, the 
bone was broken across two inches and a half above the condyles ; 
in another case, published by M. Ruyer, in its inferior fourth; lastly, 
in a specimen sent me by M. Huguier, represented in Fig. 41, the 
fracture is not more than a few millimetres above the outer condyle, 
nor more than two centimetres above the inner one. 

In this latter case the other fracture is very nearly vertical, and 
passes through the middle of the articular surface. Is it so also 

* See for the simple fractures. Desault, Journal de Clur., tome iv, p. 163 ; 
Ruyer, Beet Medicale, March; 1834; Goyrand, Traits de pathol externe, by 
Yidal, tome ii, p. 109 ; Huguier, These de Concours, 1842, pp. 26 and 30. Of 
the four compound fractures, three are reported by Sir A. Cooper, and one by 
Lonsdale. 

(445) 



446 A TREATISE ON FRACTURES. 

when the transverse branch is as high up as seen by Ivimy and 
M. Ruyer? Have we not then rather an oblique fracture separating 
one condyle from the rest of the bone, as in several forms just de- 
scribed, with a transverse fracture of the body of the bone entirely 
independent of the first? We need further facts in order to answer 
this question. 

The phenomena are those of fracture above the condyles, com- 
bined with those of separation of the condyles; and they are more- 
over very variable. Desault noted in his patient a considerable 
swelling around the elbow, and severe pain, especially in flexing and 
extending the forearm. The transverse fracture of the body of the 
bone has been recognised by the deformity of the part, by its pre- 
ternatural mobility, and by crepitation; as to the vertical fracture, 
by grasping one condyle in each hand, we can move them upon one 
another, eliciting distinct crepitation. M. Ruyer speaks also of 
swelling, deformity, and double crepitation; he adds that the fore- 
arm was semiflexed and pronated; and in moving the two condyles 
in opposite directions he took the precaution of having the upper 
fragment steadied by an assistant. 

The nature of the deformity is not indicated; probably the lower 
fragment was drawn upward and backward, and the elbow widened 
by the separation of the condyles. But M. Huguier has noted another 
kind of displacement, which I was unwilling to have represented in 
the figure, since it would have obscured the direction of the two 
fractures ; it is however easily explained when we consider the divi- 
sion of the bone obliquely downward and backward in the upper 
fracture. 

There was an overlapping of fifteen to eighteen millimetres. The 
lower end of the upper fragment, carried downward and backward, 
came to rest upon the summit of the olecranon, in front of the tendon 
of the triceps, thus by its own projection lessening the normal pro- 
minence of the olecranon; besides which, its lateral angles formed 
two small sharp points on each side of the tendon. The two lower 
fragments had ridden up forward, carrying along with them the 
bones of the forearm, and formed above the bend of the elbow a 
slight transverse prominence, limited on each side by the lower 
tuberosities of the humerus. The forearm was in a state of nearly 
complete extension; the tendons of the biceps and brachialis anticus 
were midway between relaxation and tension; the mobility was con- 
siderable, and the crepitation very easily produced, as was also the 
reduction. 

It is to be regretted that Sir A. Cooper has been silent concerning 
the phenomena presented in his cases of compound fracture. In one 
case, Ivimy noted only that the bone forming the greater sigmoid 
cavity was broken into several pieces, three of which were extracted 
through the wound. It may be seen from Fig. 41, that in M. Huguier's 



A TREATISE OX FRACTURES. 447 

patient the cavity for the olecranon has lost a portion of its wall; 
and another fracture, vertical but incomplete, may be seen divid- 
ing the inner fragment. In another case Sir A. Cooper says that 
a portion of the inner condyle protruded through the integu- 
ments. 

The diagnosis of this fracture has been already marked out in the 
description of its symptoms. The prognosis, in simple cases, is not 
very grave. Desault's patient was discharged from the Hotel-Dieu 
on the thirty-seventh day, with the fracture well consolidated, and 
with already very extensive motion of the joint. M. Ruyer says that 
in his patient, on the thirtieth day, consolidation was perfect, and 
all the movements restored; which however seems to me somewhat 
difficult to believe. Even when complicated with a wound, this frac- 
ture is not so grave as we should be led to suppose. One patient, a 
woman of fifty-six, died on the fifth day; another patient recovered, 
but with notable loss of the movements of the elbow; and Ivimy's 
case was still more successful, since the woman regained in great 
measure the motions of flexion and extension. 

The double indication offered, whether in making reduction or in 
choosing our apparatus, is to bring together the separated condyles, 
and to correct any displacement from the upper fracture. 

The forearm being flexed at a right angle, Desault surrounded the 
upper half of the forearm, the elbow, and the middle of the arm, 
with a roller, making several figure-of-8 turns around the condyles; 
he then placed one bent splint in front and another behind, and a 
solid splint on each side; the whole being confined by fresh turns of 
the bandage. 

M. Ruyer uses simply Boyer's apparatus for fracture above the 
condyles. Sir A. Cooper has represented in his Atlas two lateral 
angular splints for these cases, like those of Henckel for the fracture 
just named. 

Without doubt these appliances are sufficient when we have merely 
to bring the condyles together ; or we may resort to that advised by 
Lonsdale, a pasteboard trough receiving the elbow and half of the 
arm and forearm. But if there exist a displacement such as was 
ed by M. Huguier, or analogous to those pointed out in frac- 
ture above the condyles, we must at once employ the same apparatus 
as in the latter case. 

An essential point here is to guard against anchylosis. On the 
twenty-second day, Desault and M. Buyer laid aside the splints and 
began making passive flexion and extension of the forearm ; they 
left off even the bandage after the thirtieth day. The success attend- 
ing this plan affords a strong reason for imitating it. 

The existence of an external wound calls for some modification of 
the apparatus. We must still keep up the flexion; but we must at 
the same time leave the wound exposed, in order to dress it. This 



448 A TREATISE ON FRACTURES. 

we can do by notching the pasteboard splints, or by using a fenes- 
trated immovable apparatus. In the case reported by Lonsdale, 
there were several wounds at the elbow; Mr. Mayo devised an appa- 
ratus comprising: (1) a wide splint applied to the posterior face of 
the arm; (2) another splint of the same width, intended to support 
the forearm and hand without encroaching on the elbow; (3) two 
small steel bars, reaching from one splint to the other on each side, 
curved a little outward so as not to press upon the joint; so that, 
the arm and forearm being fixed on their respective splints, the elbow 
was exposed on all sides. This apparatus is certainly very inge- 
nious ; and perhaps this would be a case in which to apply the iron- 
wire troughs, leaving a space at the elbow, so as to fulfil the same 
indication with less trouble. As to the treatment required for the 
wound itself, it has been spoken of in connection with compound 
fractures generally ; and I shall recur to it in discussing comminuted 
fractures of the elbow. 



§ II. — Fractures of the External Condyle. 

These fractures, if I may judge from my own experience, are the 
most common of all those which affect the articulating extremity of 
the humerus, and perhaps the most common of all those of the elbow\ 
They are met w T ith chiefly in young subjects, and almost always from 
falls on the outer part of the elbow, this being close to the trunk. 

Several varieties of them have been described. Sir A. Cooper has 
given a drawing of one which passes along the upper edge of the 
condyle in front, to run finally into the joint; and he calls it an in- 
stance of intra-capsular fracture. I would observe in this respect 
that if this fracture was seated within the capsule in front, it was 
necessarily outside of it posteriorly; Sir A. Cooper's name for it 
cannot therefore be considered suitable. Some modern authors also 
have spoken of a fracture which did not penetrate into the joint, and 
which only involved the little projection of the epicondyle; but 
hitherto no one has given an instance of it. I assert therefore that 
all fractures of the external condyle are partly intra and partly 
extra-articular; and I admit but two essential varieties, one in which 
the solution of continuity involves only the condyle, the other in 
which it extends to the middle of the trochlea.* 

I have given in Fig. 46 an example of the first form. The frac- 
ture is of long standing; yet in spite of the deformity induced, we 
may get a correct idea of it from the drawing, by taking into account 
the narrowness of the detached portion; and in the specimen itself 

* [The condyle being the surface for the head of the radius to play upon, 
while the trochlea is the inner and hour-glass-shaped portion which articulates 
with the ulna.] 



A TREATISE ON FRACTURES. 449 

we see that at the posterior surface the fracture passes along the 
edge of the sigmoid cavity, which is hardly encroached upon by it. 
In Figs. 42, 43, and 44, the fracture, which is very oblique, has gone 
through the middle of the trochlea, the outer portion of which forms 
part of the detached fragment. 

Here then are at once two great varieties, according as the con- 
dyle is broken oflf alone, or carries with it part of the trochlea. This 
being well established, it must be added that these fractures, like all 
others, vary greatly according as the periosteum remains intact,* is 
torn to any degree, or is widely ruptured in the whole extent of the 
fracture. 

In the first case there is no displacement; swelling more or less 
marked occurs at the outer side of the elbow, there is pain on pres- 
sure, especially about an inch above the epicondyle, and pain when 
the forearm is flexed or extended ; these are the only phenomena 
that would make us suspect fracture; and the only means of arriving 
at a positive diagnosis is by crepitation, which is best elicited by 
putting the hand and forearm through the motions of pronation and 
supination. 

Slightly as the periosteum may be torn, two symptoms present 
themselves in addition to the above, namely: mobility and displace- 
ment. The mobility is easily detected, unless the swelling be too 
great, by putting two fingers, one in front and the other behind the 
outer fragment, and moving it in these two directions. The most 
common displacement is due to the muscles attached to the epicon- 
dyle, which draw forward the upper extremity of the outer fragment ; 
sometimes there is also a backward movement of its lower extremity, 
which carries with it the head of the radius ; lastly, I have sometimes 
detected a widening of four to six millimetres in the space comprised 
between the two tuberosities, showing that the outer fragment was 
pushed outward. As to the inclination forward of the upper ex- 
tremity of the fragment, there is one point not without importance; 
sometimes this displacement is so marked as to persist even after 
consolidation; at other times it is so slight that it seems wholly to 
disappear when the forearm is flexed ; but it is reproduced by making 
at the same time extension and pronation, a fact which affords valuable 
aid in the diagnosis, and a not less useful indication for the treatment. 
It may be also that the muscles attached to the epicondyle keep the 
forearm in a state of constant supination; Desault saw such a case.* 

But when by the external violence all the tissues capable of hold- 
ing the fragments together are ruptured, then the displacement be- 
comes so considerable that the articulation itself takes part in it, and 
there is an actual luxation accompanying the fracture. This is what 

* (Euvres Posthumes ; M6m. sur la fracture de Vextr4mit6 infe'rieure de Vhu- 
me'rus, etc., \ vi. 

29 



450 A TREATISE ON FRACTURES. 

had occurred in the specimen represented in Figs. 42, 43 and 44. 
F(<;. 46 shows a luxation of another kind, independent of the frac- 
ture, although due to the same cause; but I merely allude here to 
these various complications, to which I shall again refer in treating 
of luxations. 

Is it possible for us to ascertain, in the living subject, whether the 
fracture is limited to the condyle or extends to the trochlea? When 
the displacement is considerable, and especially when it involves an 
actual luxation, it is easy to follow the direction of the fragment, and 
to perceive that the joint is compromised; otherwise we can only 
form conjectures; and even for this the swelling must not be so great 
as to prevent examination. 

The prognosis varies in different cases. Sir A. Cooper has as- 
serted that oblique fractures, situated in great part outside of the 
capsule, will at length consolidate ; while intra-capsular cases remain 
obstinately ununited. I have already said that this distinction was 
inadmissible ; and the following are the results of my experience in 
regard to this. 

All such fractures without displacement unite readily, as far as we 
can judge from examination during life; and M. Nelaton has told me 
that he had in his possession a specimen in which consolidation was 
perfect. When the displacement is somewhat marked, and especially 
when the fragments are separated laterally, union may still occur, 
but requires a much longer time. Lastly, when the fragments are 
entirely disjoined, sometimes they remain separate, or at most union 
takes place by fibrous tissue {Fig. 46); or they may work upon one 
another, wearing one another away, becoming eburnated, and re- 
maining connected only by a sort of external fibrous capsule, {Fig. 
44.) 

While the fragments are worn away at their surfaces, there is a 
very curious phenomenon occurring ; namely hypertrophy, affecting 
the adjacent portions either of the fragments themselves or of some 
contiguous bones. The inner portion of the trochlea, {Figs. 42, 
43, 44.) the articular surface of the condyle and those of the ulna, 
and the head of the radius, have especially undergone an exag- 
gerated development; and Fig. 46 represents the same thing in a 
less marked degree. Finally, in both specimens we observe small 
rounded bits of bone, such as we shall find in much greater number 
in cases of crushing of the elbow; are these modified splinters? 
This seems to me most probable ; but hitherto it has been only in 
fractures of the elbow that I have met with anything similar. 

The treatment, when there is no displacement, consists merely in 
keeping the elbow semiflexed and immovable for twenty-five or thirty 
days, making some passive motion after the twentieth day, to pre- 
vent trouble from articular stiffening. When the condyle is broken 
off and drawn forward, the fractured surfaces should be first brought 



A TREATISE OX FRACTURES. 451 

in contact, and then the fragment put in a better position. Desault 
used in such cases the same apparatus as for fracture of both con- 
dyles : Sir A. Cooper applied merely a roller round the elbow, and a 
curved splint or pasteboard trough to support the elbow and forearm; 
or sometimes two lateral splints. For my own part, in a case of 
slight displacement in a boy nine years old, I applied a starched 
bandage, putting a graduated compress in front of the elbow, to push 
backward the upper end of the fragment, which tended to start 
forward; and the union was easy and perfect. If the projection 
forward were more obstinate, I should not hesitate to resort to the 
apparatus which I have recommended for fracture above the con- 
dyles. 

For the rest, if the union is fibrous merely, the joint is not in 
much danger provided the fragments are not too widely separated. 
I saw in consultation with M. Amussat a child of twelve years, who 
for nearly two months had had a fracture of the external condyle, 
and as yet no consolidation. The space between the two tuberosities 
was increased by six or seven millimetres; the upper end of the 
fragment projected forward, its lower part about two millimetres 
backward; motion was much impeded, and there was still pain in 
the elbow; we thought that the joint would never wholly recover its 
mobility. However, by means of poultices to relieve the pain, and 
carefully directed exercise, the movement gradually increased; and 
when I again saw the child, nearly two years afterwards, flexion, 
pronation and supination were complete; extension was lost only to 
the amount of a few degrees, and there was every promise of its full 
restoration; the only remaining annoyances from the fracture were 
the persistent deformity of the elbow, a slight displacement of the 
head of the radius backward during extreme extension, and lastly 
flying pains about the elbow upon any change of weather. 

This fracture may, like the preceding, be complicated with a 
wound, and calls for like treatment. Desault mentions a case of the 
kind, which resulted favorably. 

Finally, the same violence which produces the fracture may some- 
times cause also a luxation to either side ; but this will be treated of 
elsewhere. 



§ III. — Fractures of the Trochlea, or Internal Condyle. 

Desault was the first to mention this fracture. After him Sir 
Charles Bell, in enumerating the fractures of the humerus near the 
elbow, speaks of those of the trochlea, and not of those of the ex- 
ternal condyle, as though the former alone were exposed to separa- 
tion from the rest of the bone. Sir A. Cooper says that this fracture 
is frequent, especially in children, although he has seen it also in 



452 A TREATISE ON FRACTURES. 

persons more advanced in life. In spite of this triple authority, I 
regard the lesion as extremely rare. For my own part I have never 
soon it; neither Desault nor Sir C. Bell relates instances of it; in the 
only case cited by Sir A. Cooper, there was at the same time fracture 
of the condyle and fracture of the olecranon, which would amount to 
a comminuted fracture of the elbow ; nor could I present, as a sim- 
ple fracture of the trochlea, (although this constitutes certainly a 
part of the lesion,) the formidable injury displayed in Fig. 45. 

[In May, 1856, I saw a washerwoman, aged about 50, who had 
the inner condyle separated in consequence of great muscular exer- 
tion in lifting a heavy tub. The injury had taken place some two 
months before; there was much effusion into the cavity of the joint, 
and the heads of the radius and ulna were wide apart, but some use 
of the arm remained. The nature of the lesion was quite clear, and 
her account a plain and straightforward one. I was unable to follow 
the case up.] 

M. Gue'neau de Mussy has presented to the Societe Anatomique 
a humerus in which may be seen a fracture of the internal condyle, 
of ancient date; the sigmoid cavity is divided into two portions by 
an osseous ridge, not occupying its entire depth.* Here is established 
at once the existence of such a fracture by itself, and the possibility 
of its consolidation. Had there been in this case any displacement 
originally ? Our information on this point is deficient ; we can only 
presume that, like that of the outer condyle, this fracture may exist 
without notable displacement. 

When the fragments are forcibly separated by the external vio- 
lence, the injury, according to Sir A. Cooper, presents peculiar 
phenomena. The detached portion is carried backward, drawing 
with it the ulna, with which it is articulated ; so that the projection 
backward of the olecranon on the one hand, and the projection for- 
ward of the broken part of the humerus on the other, combine to 
simulate luxation backward of the ulna. But these deceptive ap- 
pearances are only present when the arm is extended; when we 
bring it into flexion, the ulna resumes its normal position. So also 
the forearm, which in extension inclines inward with the hand, is re- 
stored to its usual direction when it is flexed; and lastly, if any 
doubt remains, we have only to grasp both condyles with one hand, 
while with the other we put the forearm through the motion of 
flexion and extension, to perceive a crepitus plainly referable to the 
inner condyle. 

Should not this description of Sir A. Cooper's, and his remark 
as to the difficulty of diagnosis between the fracture in question and 
luxation, go to clear up the true character of some cases communi- 
cated in 1828 to the Aeademie de Medecine f A woman aged 45 

* Bulletins de la Socim Anatomique, 1837, p. 98. 



A TREATISE OX FRACTURES. 453 

had fallen upon her elbow : M. Caffort immediately diagnosed a 
luxation, and accomplished reduction with a facility which surprised 
him. Afterwards, passing his fingers along the borders of the joint, 
he perceived that the inner condyle of the humerus was very mova- 
ble ; and a distinct crepitus added to this left no doubt as to the 
existence of a fracture. M. Caffort asked himself whether the 
fracture had preceded the luxation, or the luxation the fracture, and 
inclined to the former idea. The question was not discussed by the 
Academy: M. Hervez de Che'gom said he had seen two analogous 
oases, but spoke only of their treatment.* It would seem to me ex- 
tremely probable that there was nothing but a fracture simulating 
luxation. 

Sir A. Cooper had at first recommmended in these cases the same 
treatment as for fracture above the condyles. But subsequently he 
contented himself with advising merely a roller around the elbow to 
keep the fragments in contact, the forearm being also flexed and sup- 
ported by a sling. IS. Caffort likewise applied merely a bandage; 
and M. Hervez de Chegoin also said that splints were useless, pro- 
vided the forearm was kept flexed, since then the muscles attached 
to the epitrochlea were relaxed. 

I think that all that was said concerning the treatment of frac- 
tures of the external condyle is perfectly applicable to this case also, 
and therefore refer the reader to the preceding section. 



§ IV. — Fractures of the Olecranon. 

This injury, somewhat more common than the foregoing, is never- 
theless very rare, since during eleven years it occurred only nine 
times at the Hotel-Dieu. Hoin did not see it once during thirty 
years of service in the hospital at Dijon, and his private prac- 
tice afforded him but two instances of it. Camper likewise had met 
with it in but two instances in the living body. [During the last 
five years, eleven cases have been treated at the Pennsylvania Hos- 
pital, and one has occurred to me in Dispensary practice.] This 
rarity may explain why, after being mentioned by Hippocrates, 
Celsus. and Galen, fracture of the olecranon suddenly fell into com- 

* i?T MSdicale, 1828, tome iv. p. 367. I should mention that in the Ar- 
chives Girt, de Jftdecine, tome xviii, p. 450, a somewhat different statement is 
given. Thus the patient is said to have been not a woman, but a man ; M. Caf- 
fort is said to have added to his bandage two lateral splints of pasteboard, notched 
at their lower part to receive the condyles ; and lastly Larrey, before M. Hervez 
de Chegoin, is said to have declared that the splints were of no use. and that 
he himself had successfully treated an exactly similar case by a simple bandage 
and position. The Archives state the term required for consolidation, in both 

■ have been forty days. Compare also the Journal Gen. de M& 
tome cv, p. 273. 



454 A TREATISE ON FRACTURES. 

pleto oblivion, not to reappear until the middle of the eighteenth cen- 
tury, in Duvorney's treatise. Since then it has been the subject of 
some interesting researches.* 

Men would seem more liable to it than women. I have collected 
twenty-nine cases from other authors, and six more from my own 
practice ; of these thirty-five cases, only thirteen were women ; and 
so also of the nine patients at the Hotel-Dieu, there were six men 
and three women. It affects all ages nearly alike ; of the nine patients 
at the Hotel-Dieu, three were between eleven and fifteen years old, 
and two seventy-three and seventy-four ; the remainder were of vari- 
ous intermediate ages. The cases I have collected have given me 
nearly the same result. 

The most common cause is a fall on the elbow; this was given in 
twenty-seven of my thirty-five cases. Three times only the olecra- 
non was broken by a blow with a stick or by the kick of a horse ; and 
it is doubtless on account of the small surface presented by it that it 
so generally escapes direct violence. [In all the Pennsylvania Hos- 
pital cases direct violence is recorded as the cause. My own case 
was that of a very old woman, who in ascending a stairway came 
down on her elbow; she was very heavy, and there was a pebble 
lying on the step, upon which she struck.] Lastly, in five cases the 
fracture was ascribed to muscular action; but instances of this kind 
need to be very carefully inquired into. 

The first is given by Bottentuit. A young man, trying to ward 
off a thrust while fencing, contracted his muscles so powerfully that 
he had the olecranon fractured. f This would seem to leave no doubt; 
but I find in the thesis of Capiomont an account of a similar frac- 
ture, also in a young man; Bottentuit, being consulted, attributed it 
to muscular action ; and as he declares quite plainly that he saw but 
one case of this kind, it is fair to presume that the two accounts refer 
to one and the same case. Now Capiomont tells us that Deleurye, 
who came in after Bottentuit, asserted that the fracture could not 
have been caused by anything but a fall; hence the case must remain 
at least doubtful. 

Capiomont gives also an account of a drunken horseman, who in 
beating his horse was thrown, and had his olecranon fractured, al- 
though he did not strike his arm in his fall. This fact of the fall 
leaves much doubt in my mind, especially as the story was derived 
from a drunken man. A third instance, reported by the same 
writer, may be considered as conclusive. A gunner, while working 

* See Camper, Diss, de fract. patellce et olecrani, Hagge Com., 1789; Haigh- 
ton, in Duncan's Med. Comment., vol. ix, p. 382 ; Desault, Journal de Chirur- 
gie and (Euvres Posthumes ; Capiomont, Tliese inaug., Paris, an xi, No. 19; 
and Thierry, Thdse inaug., Paris, an xiii, No. 349. 

f Journal GtneTal de Medecine, tome xxiv, p. 377. 



A TREATISE ON FRACTURES. 455 

at a capstan, "was left alone for some moments, and making a violent 
effort with his right arm, heard a crack, and instantly lost all power 
in the limb ; the olecranon was ruptured. Richerand saw a similar 
result from an effort to throw a ball to a very great distance, and 
M. Blandin, from the motion of extending the arm in diving.* 
Lastly. I have myself had occasion to examine a man thirty years 
old, who, in playing with a comrade, his arm being stretched out, 
had his vrrist suddenly struck so as to forcibly flex the forearm in 
spite of the resistance of the triceps ; he felt at the time a pain like 
the prick of a needle, but did not give up work for several days; 
afterwards, flexion becoming more and more painful, he consulted 
M. Yeyne and M. Robert, who made out a detachment of the apex 
of the olecranon. 

As far as we can judge from so small a number of cases, it would 
seem that for the occurrence of these fractures there must be a cer- 
tain degree of flexion of the forearm, this latter being then subjected 
to a force tending to flex it still further, which is resisted by the tri- 
ceps. It is thus that the olecranon is broken in certain imprudent 
attempts at the reduction of old luxations of the elbow; I shall speak 
of this again at the proper time and place. 

These fractures present several varieties, according to their seat. 
Desault was the first to distinguish two species, those of the summit 
and those of the base;f to which Boyer added a third, those of the 
middle portion. The base, referred to by Desault, was doubtless the 
same part which was called by Boyer the middle; but however this 
may be, I have made out really three varieties, corresponding very 
well with Boyer's division. 

Fractures of the apex are the rarest of all; I can quote but two 
instances. They consist in a tearing off of the cortical layer which 
receives the insertion of the triceps, and in both those cases were 
the result of muscular action. This was what had occurred in the 
patient whom I saw after MM. Yeyne and Robert; in the cannonier 
spoken of by Capiomont, although the description is deficient, we 
may presume that there was a rupture of the same kind, since several 
surgeons had called it a mere decollation of the tendon. Does the 
fracture in these cases communicate with the joint? I merely pro- 
pose this question, not having the positive facts necessary for its 
solution. 

Fractures of the middle portion are the most common of all; they 
divide the process just where its articular cartilage ends, where 

* Gazette des TTopitaux, 1845, p. 327. s 

t M. Littre has found this distinction made by Hippocrates, but by adding to 
the text a sentence of Galen's Commentary, preserved by Oribasius. I am afraid 
this interpolation is somewhat over-bold ; and the expression used by Oribasius 
himself is very obscure, and susceptible of more than one interpretation. 



456 A TREATISE ON FRACTURES. 

the sigmoid cavity diminishes in size ; their direction is nearly hori- 
zontal. These are, according to Desault, fractures of the base, and 
according to Cooper, fractures of the middle ; they are said by 
both to be transverse; but on close examination it is extremely rare 
not to detect even during life a certain degree of obliquity from one 
side to the other, as in Fig. 47 ; and in the same specimen there was 
besides a marked obliquity from above downward, and from behind 
forward, (Fig. 49.) 

Lastly, what we may call, if we choose, fractures of the base, are 
such as, running very obliquely from above downward and from before 
backward, commence within the articulation at the same level as the 
preceding, but descend backward so as to detach from the ulna the 
entire posterior and triangular face of the olecranon. I have twice 
seen this lesion in the living subject; and in one remarkable instance 
the fracture gave rise to luxation forward of the forearm. 

Besides these principal varieties, the fracture may also be simple, 
or attended with some splintering, or even present the phenomena of 
actual crushing; finally, it is sometimes complicated with an external 
wound. 

The phenomena of this injury are, in the first place pain, sudden 
loss of the power of flexing and extending the arm, contusion when 
the cause has been external violence, and almost always a greater or 
less degree of swelling. The examination being carried further, the 
elbow is found deformed; the olecranon more or less drawn up be- 
hind the humerus, and therefore out of line with the posterior edge 
of the ulna, and making a much smaller prominence posteriorly. 
Between the two fragments is an interspace, rarely perceptible to the 
eye, but into which the finger may be readily pressed ; and if the two 
forefingers be applied, one on each side, fluctuation is perceived, 
sometimes doubtfully and sometimes very plainly. The separation 
increases when the forearm is flexed, diminishes when it is extended, 
and disappears if when the forearm is extended the upper fragment 
is brought down. By seizing this fragment between two fingers, we 
may move it to and fro from one side to the other; and by bringing 
it against the other, crepitation is quite readily elicited. 

Let us dwell for a moment on some of these phenomena. The 
impossibility of flexion and extension of the arm does not arise from 
want of muscular power; the triceps is continued upon the ulna by 
the fibres of the anconeus, and the flexors have, on the other hand, 
a feebler opposition to encounter. But besides the pain, the swelling, 
and the effusion of blood within the joint, it must be observed that 
every contraction of the muscles, either in extending or in flexing 
the forearm, tends essentially to separate the fragments, and to 
stretch or even break the fibres which still unite them; thus one of 
Desault's patients said, on attempting to extend the arm, that he 
felt something broken aivay from the elbow. If the pain is trifling, 



A TREATISE ON FRACTURES. 457 

the movements are executed freely enough ; I have even seen one 
case in which the man kept at his work as a tailor for two or three 
days after the accident; and afterwards, before union was complete, 
the motions were regained in proportion as the pain and swelling 
subsided. 

The separation of the fragments has also a certain importance; it 
is sometimes hardly perceptible. Monteggia says he saw fractures 
of the olecranon from falls on the elbow, without any displacement 
whatever ; and Sanson met with a case of the same kind. Sir A. 
Cooper explains this by the preservation of a special fibrous band 
extending obliquely from the coronoid process to the olecranon, and 
also of that part of the annular ligament of the radius which is fas- 
tened to the detached portion. Without denying the slight action of 
these fibrous fasciculi, it should not be forgotten that the olecranon 
is held laterally by the capsule of the joint, and especially covered 
posteriorly by a very thick periosteum, strengthened still more by a 
prolongation of the tendon of> the triceps; if this fibrous envelope 
remains intact, there can be no displacement; and the separation 
doubtless arises at once from its rupture and from that of the cap- 
sular ligament. 

As to the extent to which it may occur, Capiomont and Thierry 
cite cases in which it amounted to two fingers'-breadths ; Sir A. Cooper 
saw it in one case as much as two inches. In this latter case, it should 
be mentioned, the capsule was torn through on each side of the ole- 
cranon : but what is particularly to be noted, he has represented this 
separation as increased by flexion of the forearm ; whereas to judge 
of its actual degree the limb should be extended, as in the case of the 
patella. I doubt very much whether the separation would be thus 
found to be so considerable; and for my own part I have never seen 
it much over a single centimetre. 

Finally, in reference to this separation, I must not omit to say 
that sometimes it does not show itself at the moment of the fracture, 
but comes on afterwards, as the effect of some sudden movement or 
of some fresh violence from without. Lonsdale quotes from Earle a 
case of fracture of the olecranon, in which the separation did not 
occur until the sixth day, and was then produced by a motion made 
by the patient in putting on his cravat. 

These are, so to speak, the general symptoms ; they are not the 
same in all the varieties. In fractures toward the summit, the de- 
tached fragment being very thin, the shape of the elbow is scarcely 
altered ; so that in one case, as has been said, a mere rupture of the 
tendon was diagnosed. In those of the middle portion, the separa- 
tion is more marked than in the others, and sometimes allows the 
finger, the forearm being flexed, to reach the trochlea ; or, the fore- 
arm being extended, to pass into the sigmoid cavity. Fractures of 
the base have a special character owing to their obliquity ; the upper 



458 A TREATISE ON FRACTURES. 

fragment is pointed, and stretches the integuments, while below it may 
be felt the ulna, bevelled at the expense of its posterior face. Per- 
haps an attentive examination would detect some preternatural mo- 
bility in the articulation of the ulna with the humerus; but having 
only seen these fractures a long time after their occurrence, I put 
forth this idea as a mere conjecture, to be tested. 

As to splintered and crushed fractures, I have nothing particular 
to say here. In fractures complicated with a wound, there is some- 
times a slight but persistent hemorrhage from the broken ends ; I 
shall mention such a case in connection with comminuted fractures 
of the elbow. 

The course of these fractures is ordinarily very favorable. The swell- 
ing disappears at about the tenth or fifteenth day, and union occurs 
quickly and firmly. According to Bichat, of eleven fractures of the 
olecranon treated in Desault's wards, four were united by the twenty- 
third day, three by the twenty-eighth, and four by the thirty-second. 

But what is the nature of this union? In the living subject, when 
there remains some degree of separation, and the upper fragment is 
movable upon the other, it is manife'stly fibrous ; when the fragments 
are close together and immovable, we may presume that the callus is 
ossified. In order to clear up this point, Sir A. Cooper fractured 
the olecranon transversely in a dog and in several rabbits. Finding 
union always fibrous, he varied the experiment by dividing the pro- 
cess by a somewhat oblique vertical section, so that the two portions 
should remain in contact ; and this time he obtained an osseous 
callus. Hence he concluded that want of contact was the only diffi- 
culty in the way of bony consolidation, which might be insured by 
approximating the fragments. I have represented, in the atlas to 
my volume on Luxations, such a fracture of the olecranon compli- 
cated with a dislocation of the elbow, but united again by bone. 

It nevertheless appears that union is most commonly fibrous, either 
from some defect in the treatment, or from the form of the fracture. 
Desault and Sir A. Cooper each examined by dissection an old frac- 
ture of the olecranon, and in both cases the union was entirely 
fibrous. It may be alleged that the fragments had remained wide 
apart; but in the specimen I have had drawn, {Fig. 48,) the separa- 
tion, especially on the outer side, is not very considerable; and yet 
there was no trace of ossific callus. 

The fibrous tissue connecting the fragments is not even so firm as 
might be thought. Sir A. Cooper has remarked that it often, when 
of considerable length, presents one or more lacunae. In Fig. 47 is 
seen such a lacuna, separating the fibrous callus into two lateral por- 
tions. But there is another fact of much greater importance; the 
fibrous tissue is not attached by the whole extent of the fractured 
surfaces ; sometimes it is limited to their circumference, within which 
there is no attachment of any sort, as was very well marked in the 



A TREATISE ON FRACTURES. 459 

specimen represented in Fig. 49 ; Sir A. Cooper's drawing seems to 
show a similar arrangement. Sometimes the fragments, farther sepa- 
rated posteriorly than anteriorly, are only in contact by their ante- 
rior edge ; this was found to be the case in M. Pasquier's patient, 
who was treated with the forearm at an angle of forty-five degrees, 
and who died three months after the receipt of the injury.* 

Lastly, the uniting membrane may be entirely wanting; at least 
I have seen, in a trooper who had a very old fracture at the base of 
the olecranon, the upper fragment remaining quite immovable during 
flexion and extension of the arm, although it could be easily worked 
from side to side. 

An important subject for study is the influence of fibrous union on 
the power of the limb. In 1785, Haighton reported the case of a 
boy of fifteen, who having had a fracture of the olecranon which was 
treated as a mere contusion, never completely regained the power of 
extending the arm. Sir A. Cooper asserts that the loss of force is 
in proportion to the length of the intermediate band; and that when 
this is very long, it diminishes the strength of the triceps, thus hin- 
dering extension. This idea has greatly prevailed among surgeons, 
leading them to keep the limb extended in order to prevent separa- 
tion of the fragments. 

There are however quite numerous facts showing this fear to have 
been at least exaggerated. Camper first gave an account of two 
transverse fractures, treated by means of the sling merely, united by 
fibrous tissue, and yet preserving to the injured limb an extension as 
complete as that of the sound one. Capiomont and Thierry have 
reported analogous cases; Boyer saw two instances in which the 
fibrous band was half an inch in length, but the forearm had re- 
covered perfectly its motion and its strength. I have myself ob- 
served something still more remarkable ; in the trooper before men- 
tioned, in whom the fragment was unaffected by the movements of 
the ulna, extension was perfect, and the development of the limb was 
unimpaired. 

Must we then believe that it is a matter of indifference that the 
olecranon is more or less elongated by intermediate fibrous tissue ? 
Such is by no means my conclusion. As to the cases related by 
Camper and others, I doubt much whether the liberty of movement 
was so great as they would make us think, especially considering the 
new relations of the ulna, shown in the specimen which I have repre- 
sented in three different aspects. {Figs. 47, 48 and 49.) We see, 
indeed, in Fig. 48, that the apex of the process is carried farther 
forward than naturally; in Fig. 49 that the fragments are farther 
apart behind than in front, which is explained by the preceding fact; 
in Figs. 47 and 48, that the separation is wider at the inner or ulnar 

* Gazette des Hopitaux, 1830. p. 109. 



460 A TREATISE ON FRACTURES. 

edge than at the outer, whence the apex of the olecranon is inclined 
over outward, coming into the same vertical line with the lesser sig- 
moid cavity. The inclination forward of the apex of the olecranon 
had also given rise at length to a flattening of that of the coronoid 
process ; and all these little alterations of form and of relation would 
seem to me necessarily to involve some loss of freedom of motion. 

The case in question was one of fracture of the middle portion ; 
in ohlique fractures of the base, direct observation has discovered to 
me phenomena much more unexpected. In a woman aged 39, who 
had for four years had an ununited oblique fracture, I noted parti- 
cularly, that she could freely grasp any object when her arm was 
hanging down and her forearm flexed ; but that if she stretched out 
the forearm, the fingers lost their power; and that if she at the 
same time raised the arm, her hand could no longer hold anything, 
relaxing involuntarily. But this was so singular, that I hesitated to 
attribute it to the mere fracture; another case was needed to assure 
me, and at the same time to put me in the way of plausibly explain- 
ing it. 

This case I found in that of the trooper before mentioned, whose 
injury dated back twenty-five years. The limb as a whole was as 
well developed as the sound one; the patient could extend the fore- 
arm strongly, or grasp anything with his hand, and wielded a sword 
or a foil with quite uncommon power. But all this he could only do 
when the forearm was either supinated or in a middle position be- 
tween this and pronation, and the arm lowered or only moderately 
raised. The hand when pronated was not so strong; when the arm 
was raised horizontally, it was much weakened; and any further 
elevation of it almost deprived him of the power of holding any- 
thing. Thus in the use of weapons, he had been obliged to abandon 
the back-sword; and he had likewise to avoid carefully any manoeuvre 
in which his arm would be elevated. 

I several times studied the conditions of this phenomenon, with 
the following results. When the extended forearm was raised to 
the level of the shoulder, the head of the radius passed forward 
about one-fifth of an inch, leaving the condyle of the humerus pro- 
jecting just as far beyond it backward; the same thing occurred 
during pronation; but on the sound side there was nothing of the 
kind. Here was then a subluxation of the radius, produced in great 
measure doubtless by the action of the biceps; and probably the 
ulna underwent a similar displacement. But why was it peculiar to 
certain positions? This I cannot say; the phenomenon however 
seems to me to be confined to oblique fracture of the base of the 
process, for in an old fracture at the middle portion, which I lately 
had occasion to examine, the patient had not had anything like it. 

There is therefore, at least in certain cases, marked inconvenience 
attending deficient union, or union by fibrous tissue, in fractures of 



A TREATISE ON FRACTURES. 461 

the olecranon. But before this can be felt, there is another still 
more urgent, which the surgeon should not lose sight of; and this is 
the stiffening of the elbow in whatever position we may put it ; it is 
often very obstinate, sometimes amounting even to anchylosis; 
Trioen has given a drawing of an osseous fusion following a frac- 
ture of the olecranon, the preparation having been in the possession 
of Camper. 

Finally, I would not omit another slight consequence which I 
have remarked after fracture of the summit of the process; for a 
long time afterwards the patient is unable to raise a somewhat heavy 
weight without having a sort of cramp in the arm ; this however dis- 
appears in time. 

The diagnosis and prognosis are deduced from all the facts 
hitherto given. The swelling around the elbow is sometimes so great 
as completely to mask the fracture, leading experienced surgeons to 
take it for a mere contusion. In such a case it would be most pru- 
dent to wait, and not form any opinion at once. 

We must however guard against the opposite error, and not mis- 
take a contusion for a fracture. A woman came to consult me after 
a fall on the elbow; the skin over the middle of the olecranon was 
abraded and as it were thinned, while above and below there was 
considerable swelling; so that the nail seemed at first to pass into 
an interspace between the fragments. But there was no crepitation, 
nor mobility of the upper fragment, nor increase of the separation 
in the position of extreme flexion ; hence there was no fracture ; 
but such a case would demand careful attention. 

The treatment has been modified alternately in view of one or the 
other of these dangers, anchylosis and want of exact union. Two 
very different methods have thus arisen, according as we put the 
limb in the flexed or extended position ; they may be called the old 
and the neiv methods. 

Old Method ; Semiflexion. — Hippocrates used in this, as in other 
fractures about the elbow, a simple bandage, keeping the forearm 
semiflexed. Celsus, following doubtless some surgeon of Alexandria, 
rejected even the bandage, adding that if we only remedy the pain, 
the limb will perform its functions as well as ever. Camper, in the 
eighteenth century, first revived the idea of Celsus, and recommended 
the employment of nothing but rest and a sling. Bottentuit, resum- 
ing the practice but not the knowledge of Hippocrates, applied a 
moderately tight bandage; and the numerous partisans of semi- 
flexion have done little more than follow one or the other of these 
plans. The apparatus of Devilliers is the only one worthy of sepa- 
rate mention. 

The case was one of fracture by direct violence, with separation 
of about one inch. After treating the swelling for five or six days 
by suitable fomentations, Devilliers applied over the olecranon a 



462 A TREATISE ON FRACTURES. 

long and thick compress, which he fixed by a few loose turns of a 
bandage. To the last of these circular turns, he attached two bands; 
these were fastened by their other ends at the wrist, keeping the 
forearm permanently flexed, or at least preventing its being ex- 
tended without drawing down the bandage and compress, and there- 
fore the olecranon also. Union, according to Capiomont, took place 
quickly and completely. 

Modern Method; Extension. — This plan, first proposed by Du- 
verney, is now universally adopted in England and Germany; and 
even in France and Italy, it probably has at present the majority in 
its favor. It comprises two secondary varieties, according as the 
extension is more or less complete; partial extension, such as was 
preferred by Duverney, Desault, Boyer and Monteggia, has remained 
in a great degree peculiar to the French school ; while complete ex- 
tension, adopted by Haighton, Sheldon, Sir A. Cooper, etc., forms 
the basis of the English system. Each, again, embraces numerous 
forms of apparatus. 

Duverney 's plan is certainly one of the simplest of all; he merely 
surrounded the elbow with a moderately tight figure-of-8 bandage, 
taking care not to press upon the olecranon, and placed the arm 
slightly flexed upon a. pillow. 

Desault commenced by surrounding the forearm, up to the elbow, 
with a roller; then grasping the olecranon in his fingers, he drew it 
down toward the other portion of the ulna, with the not unimport- 
ant precaution of having the integuments drawn upward by an as- 
sistant, lest, in their relaxed state from the extended position of the 
limb, they should be caught between the fragments. Coaptation 
being thus made, the surgeon substituted for the finger holding the 
olecranon a turn of the figure- of-8, continuing this figure until the 
elbow was entirely covered, and then carrying the roller on up the 
arm. He then put a long and strong splint in front of the arm, 
fastened it there by a bandage, and placed the limb on a cushion sc* 
as to make it lie evenly. The great point was that the splint had a 
slight angle opposite the bend of the elbow ; according to Bichat, 
this should be so marked as to keep the forearm between extension 
and moderate flexion. 

Boyer used no splint. He however adopted the bandage of De- 
sault, with two modifications; first, he commenced the roller upon 
the hand, and secondly, before surrounding the olecranon with it he 
covered that process with a long compress, the two ends of which 
came forward and crossed one another on the forearm. 

These bandages are apt to become relaxed, and besides that they 
do not hold the olecranon very firmly. M. Velpeau obviates the for- 
mer difficulty by using a dextrinated bandage a good deal like that 
of Boyer, supported sometimes by long pasteboard splints. As for 
confining the fragment, Wardenburg tried a circular bandage placed 



A TREATISE ON FRACTURES. 463 

above it. drawn down by two bands going to be attached at the 
hand. Bottcher substituted for this a strap and buckle, and for the 
two bands two other straps firmly attached above to the first, pass- 
ing downward to go between the thumb and forefinger and fastened 
together by a buckle; their tightness could of course be regulated 
at will. Feiler used a bracelet above the elbow, with three buckles; 
another buckle, attached to this just over the olecranon, received 
a strap fixed below to the back of a glove.* 

It may easily be seen that these straps and buckles bring the limb 
into nearly complete extension ; let us now run over those forms of 
apparatus in which this is assumed as the leading indication. 

Camper, who introduced the idea in 1755, but renounced it almost 
immediately, employed two splints ; Haighton used a hollow paste- 
board one ; but it was soon perceived that besides a proper position, 
some special traction upon the olecranon was necessary. 

Dupuytren put an ordinary splint in front of the elbow, and acted 
on the fragment by means of a bandage like that for transverse 
wounds ; a very doubtful plan, and one already abandoned by De- 
sault himself. 

Sir A. Cooper placed a wide tape or piece of bandage longitudi- 
nally at each side of the fragment. He then applied over these a 
wet roller circularly above the elbow, and another at the lower part 
of the forearm, and brought together the ends of each tape, so that 
by drawing them tight and tying them he approximated the two cir- 
cular bands, the upper of which brought down with it the olecranon. 
A well-padded splint, placed in front, completed the apparatus, which 
was to be frequently wetted with spirits and water. 

Alcock advised the use of a much simpler means, namely, a long 
strip of diachylon or lead-plaster, the middle of which being applied 
over the upper edge of the olecranon, its two ends were brought for- 
ward and crossed on the anterior face of the forearm. f 

Amesbury, making use of Sir A. Cooper's idea, replaced the wet 
bandages by well-padded leather cushions, fixed, one above the ole- 
cranon and the other on the forearm, by three straps passing around 
the anterior splint also ; these cushions were brought toward one an- 
other by two longitudinal straps passing on each side of the olecranon. 

M. Mayor has endeavored to make with handkerchiefs an appara- 
tus like that of Bottcher, adding a hollow splint at the bend of the 
arm, to hinder flexion. He ties around the arm above the olecranon 
a handkerchief folded cravatwise ; this is drawn downward by a 
second, which is fixed by its middle between the thumb and forefin- 
ger, and the two ends of which, crossing one another at the back of 
the wrist, run up toward the elbow to be suitably attached to the one 
first mentioned. 

* See Richter's work, and especially his Atlas. 

t London Medical Repository, 1824, vol. i, p. 496. 



464 A TREATISE ON FRACTURES. 

There are two inconveniences about all these plans, and in fact about 
the entire method. The first consists in the trouble of keeping the 
limb pendent and encumbered with the apparatus ; the second is the 
impossibility of making passive motion of the joint without stripping it. 
Most surgeons who advocate this method keep their patients in bed 
until consolidation is so far advanced as to allow of the elbow being 
moved. M. Baudens, having to treat the Due de Nemours for a 
fracture of this kind, sought to avoid both these inconveniences. I 
shall pass over the apparatus itself, which was almost exactly like 
that of Dupuytren ; but in order to enable his patient to go about, 
M. Baudens had constructed a hollow tin splint, well-wadded, and 
fastened at the axilla by two straps going over and crossing one an- 
other upon the opposite shoulder ; to this splint, at about its middle, 
was jointed a wooden support eighteen inches long, which being re- 
ceived into a socket like that of a standard-bearer, fixed at the hip, 
maintained the splint and the arm in a horizontal position.* 

Such are the principal means recommended for fracture of the 
olecranon. If now we seek to estimate the value of each, it is evi- 
dent in the first place that the old method has in its favor its simpli- 
city, its facility of application, and, so to speak, its agreeableness ; 
since all that is necessary is a sling, and the patient can go about 
from the very first day, using his arm as soon as the pain abates. If 
it be true that there is no fear as to the functions of the arm after 
this treatment, it is incomprehensible that so many surgeons have 
adopted the opposite plan ; and even taking into account the actual 
consequences which I have clearly made out, I do not know that in 
a fracture of this kind in the left arm I should attach much import- 
ance to extension. But in the right arm it is another affair ; it is 
very important that the limb should lose nothing, and to say the least 
of it, the modern plan is the one which affords us most security in 
this respect. 

This being granted, the first question is how far we should carry 
the extension. Desault feared that if the arm were completely ex- 
tended, the fragments would be in contact behind, but separated in 
front ; or that if they did not come together, one of them would sink 
into the sigmoid cavity, thus passing forward out of the way, and 
leaving the other behind ; so that in either case there would be irre- 
gular union, and some impairment of motion. All this is so hypo- 
thetical that Boyer has made no account of it. According to him, 
the connection is always fibrous, and therefore the advantage of hav- 
ing a less separation of the fragments does not counterbalance the 
fatigue induced by complete extension, or the danger of articular 
stiffening from a position so unfavorable to the functions of the limb. 

In the first place, Boyer's denial of osseous consolidation is set 

* Bulletin de VAcad. de Midecine, tome ii, p. 575. 



A TREATISE ON FRACTURES. 465 

aside by facts ; and the argument as to stiffening of the joints has 
likewise but an equivocal value. Doubtless complete extension en- 
dangers stiffening of the elbow ; Thierry cites a case in which, after 
six months of painful manipulations, there still remained great -ri- 
gidity. I have myself seen an analogous case. A grenadier aged 
26, had fallen upon his elbow; the ecchymosis and swelling gave the 
idea of a mere contusion, and it was not until the sixteenth day that 
the fracture was recognised. Complete extension by means of an 
anterior splint was then resorted to; but union did not progress fa- 
vorably, and after fifty days in the hospital, although he could extend 
the forearm well, its flexion was very limited, and caused separation 
of the fragments ; the olecranon seemed anchylosed in the sigmoid 
cavity. 

But are the plans of Desault and Boyer better fitted to prevent 
these consequences? Thierry reports two cases which are quite con- 
clusive on this point. A woman with fracture of the left olecranon 
was treated with Boyer 's apparatus ; coaptation was exact, and no 
trace of the fracture remained; but the articulations of the elbow, 
wrist and fingers were so stiff that their movements were not regained 
until a year had elapsed, and then only at the price of excessive pain 
and great perseverance. Another woman, treated in the same way, 
had likewise marked rigidity of the joint ; Thierry wished gradu- 
ally to overcome it ; but the patient had not sufficient courage to 
submit, and the elbow finally became completely anchylosed. 

Thus, in these two cases, partial extension gave less favorable re 
suits than complete. But even semiflexion does not obviate the dan- 
ger of obstinate rigidity, as is shown in a remarkable instance given 
by Sir A. Cooper; and I have proved, in discussing the general sub- 
ject of anchylosis, that there is no position whatever which leads 
to this result unless when combined with too prolonged restraint. 
The true conclusion from all this is, that we should guard against 
anchylosis, without ceasing to aim at consolidation ; and not forget 
either in our anxiety about the other. 

Complete extension approximates the fragments to the greatest 
possible degree, and should therefore, generally speaking, be pre- 
ferred. As to the choice of apparatus, we should first insure abso- 
lute immobility by applying a splint, either plain or hollow, in front 
of the arm ; after this an adhesive strip, as used by Alcock, either 
by itself or with the addition of a thick compress above the olecra- 
non, i>; nssuredly the simplest means of acting efficiently upon the 
upper fragment. 

[The above plan has been followed successfully in the Pennsylva- 
nia Hospital, in the few cases of the injury in question which have 
been treated there. The adhesive strips are, however, applied first, 
and do not quite surround the member ; and the roller is made to 
extend from the fingers nearly up to the shoulder. The length of 

30 



4G6 A TREATISE ON FRACTURES. 

the splint has a good deal to do with its efficiency in restraining 
flexion.] 

If we would attain still greater security, at the expense of greater 
complication, Amesbury's apparatus seems to me to best fulfil all the 
conditions. 

Whatever apparatus we may prefer, there are some important pre- 
cautions to be observed in its application. In the first place, we 
should have the skin drawn upward, according to Desault's precept, 
to prevent its becoming engaged between the fragments. Next we 
should be careful to bring down the upper piece evenly, so that it 
may not remain inclined to one side or the other, as in the specimen 
I have had represented ; and if this inclination is the effect of con- 
traction of the triceps, we must seek to correct it. Lastly, the 
surgeon should bear in mind that in robust persons who follow labo- 
rious occupations, the forearm is no longer in a direct line with the 
arm, but generally makes a slight angle with it ; in such a case the 
shape of the anterior splint is to be accommodated to the form of the 
limb, and the bend of the elbow so padded as to prevent any dis- 
tortion. 

Another question of no less importance arises, as to the period 
when it is proper to put on the apparatus. Desault applied it at 
once, regardless of the swelling; Boyer waited for this to subside, 
and if it remained until the twentieth day, considered the organisa- 
tion of the callus sufficiently advanced to render any apparatus use- 
less. It has been seen, indeed, in the case of the grenadier just 
cited, that the apparatus, applied on the sixteenth day, did not 
diminish the length already acquired by the fibrous band. 

The rule should be the same in this as in every other fracture. 
Every enveloping and compressing apparatus is likely to do harm 
while the swelling and inflammation persist; but the position should 
be carefully attended to, if we would not run the risk of irremediable 
separation of the fragments. 

Finally, when and how is motion to be impressed upon the joint? 
Duverney only waited a few days ; Bottentuit postponed it for two 
weeks; Sir A. Cooper thought a month should be allowed to elapse, 
lest the olecranon should be forced away from the rest of the bone, 
and the fibrous tissue be stretched and weakened. I think that the 
surgeon should be governed by the degree of the foregoing inflam- 
mation, which would influence the danger of stiffening. But if it be 
thought proper to use such motion before the end of a month, it is 
important for us to observe great gentleness and caution. Botten- 
tuit fixed the olecranon with his left hand, while with his right he 
put the forearm gently through limited movements, which he repeated 
and extended every two days. There would be still less risk if the 
surgeon, grasping the forearm with both hands, should bear upon the 
olecranon with both thumbs, so as to act at once on both fragments. 



A TREATISE ON FRACTURES. 467 

M. Baudens judged it necessary, at the twenty-eighth day, to apply 
in his case a hollow splint with a hinge at the middle, the angle "being 
regulated by a screw, so as to make the movements still more exact; 
and in spite of the judicious use of frictions, douches, and exercise, 
the cure was not completed for two months. [I may say here that it 
is the opinion of many American surgeons that in all fractures near 
joints, by the exercise of extreme care in grasping and confining the 
fragment?, passive motion may be made with safety at an early 
period ; perhaps in most cases by the tenth or fifteenth day.] 

It is mainly by perseverance in exercising the elbow that we can 
hope to remedy stiffening of the joint; but we have to treat cases 
also in which the functions of the limb are impaired by the degree 
of separation of the fragments. Sheldon has given the more than 
bold advice to lay the bone bare, and to rasp the fractured surfaces 
so as to again attempt their approximation.* Wright tried in one 
case compression by means of a roller, pasteboard splints, and two 
pasteboard troughs, as firmly applied as the patient could bear; this 
apparatus was kept in place for two months, at the end of which 
time, it is stated, the mobility of the fragment had entirely disap- 
peared. Finally, it is said that Dieffenbach, in an analogous case, 
began by rubbing the two fragments together so as to cause severe 
pain, and then divided the tendon of the triceps, and kept the fore- 
arm semiflexed by means of a starched bandage. Every fifteen days 
the rubbing was repeated, and the apparatus renewed ; and \t the 
end of three months the fracture was found to be united. f I would 
not employ either of these plans, which would seem to me better 
calculated to induce stiffening of the elbow than union of the frac- 
ture ; and I notice that in these two cases we are left uninformed as 
to the condition of the elbow after the treatment, or the degree of 
benefit derived by the patient. The only rational course here again 
would be to persevere in exercising the joint, in order to increase 
the power of those portions of the triceps muscle which are inserted 
into the lower fragment. 

I shall say but a few words concerning this fracture when compli- 
cated with an external wound. If we are called immediately, we 
should try to obtain union by the first intention, and then to act as 
in a case of simple fracture. Sir A. Cooper has twice seen this plan 
successfully followed. But if suppuration occurs within the joint, 
the danger of anchylosis is too imminent for us to leave the arm in 

* An Essay on the Fracture of the Patella or Knee-pan: containing a nyw 
and efficacious method of treating that accident. With observations on the 
fracture of the olecranon. By John Sheldon; London, 1789. I have been 
unable to procure this work, and merely quote from Richtcr. [This work is in 
the library of the Pennsylvania Hospital ; the author says he has never at- 
tempted the operation, but thinks it might answer in some cases.] 

t Wright, Journal des Progrcs, tome xv, p. 103; Dieffenbach, Gazette M6di- 
cale, 1841, p. 740. 



468 A TREATISE OX FRACTURES. 

the extended position; we must, as in the case of other complicated 
fracture* of the elbow, keep it semiflexed and at perfect rest. 

§ V. — Of Comminuted Fractures of the Elbow. 

It happens sometimes, as the result of a severe fall, of the pas- 
sage of a carriage-wheel, or of the application of any crushing force, 
that the elbow is comminuted, most generally with an external 
wound. "We then meet with various combinations of the different 
fractures already mentioned, but with a great many splinters; and 
all the bony constituents of the joint may be involved. 

Fig. 45 presents the most curious example within my knowledge, of 
a comminuted fracture of the elbow brought to a comparatively very 
favorable issue. The subject was a woman aged 57 years, who twenty- 
seven years before had had her elbow crushed by a heavy gate being 
suddenly shut upon her. Enormous swelling ensued, which she 
treated by emollient poultices; at the end of three months she began 
to regain some motion, and gradually, in spite of the deformity which 
may be imagined, she acquired the power of flexing the arm to some 
extent, of carrying the hand to the head, and of pronation and 
supination. 

On examination a little while before her death, the arm was mea- 
sured, from the acromion process to the tip of the finger, and found 
shortened by one and one-third inch; the olecranon was drawn up 
about an inch on the posterior surface of the humerus, and a little 
inward also; on the outside there was felt a hollow above the tuber- 
cle of the radius ; and as in rotation there was perceived crepitation 
at this point, there was diagnosed a luxation of the ulna backward 
and a little inward, together with an ununited fracture of the upper 
extremity of the radius.* The preparation, which I have had 
drawn with the bones separated, shows also other lesions. t 

There was in the first place an oblique fracture of the trochlea, 
and crushing of the detached piece, several bits of which are seen 
like foreign bodies in the joint. The olecranon and coronoid pro- 
cesses, and the intermediate bone, were likewise crushed, and re- 
united into a wide flat surface continuous with the anterior face of 
the ulna, only crossed, below and in front by a sort of ridge adhe- 
rent by its inner end. What is quite curious, the upper and inner 
angle of this wide surface seemed formed by the epitrochlea, fused 
with the olecranon ; the muscles retained their attachments to it. 
Lastly, the head of the radius had been separated from its shaft, to 
which it was held merely by a slight fibrous band. 

What was very remarkable in this case, and what especially ac- 
counts for its favorable termination, is that with such severe internal 

* Call6, Bulletin de la SociAU Anat, 1835, p. 133. 



A TREATISE ON FRACTURES. 469 

injury there was no division of the integuments. But as has already 
been stated, this happy condition is rare ; generally there is at least 
one external wound. 

Sir A. Cooper has made a curious observation in regard to this ; 
it is, that these compound fractures generally affect the inner con- 
dyle, and he cites in fact two cases in which this portion of the bone, 
being broken, protruded through the integuments. In the only ex- 
ample of comminuted fracture of the elbow which I have seen, the 
humerus was on the contrary intact, except that its articular car- 
tilage was stripped off; the patient had fallen from a second story 
upon the elbow, and the wound answered merely to a transverse 
fracture of the olecranon, leading me to think that this process 
alone was involved. The patient dying, at the fifty-eighth day, the 
autopsy revealed a comminuted fracture of the coronoid process of 
the ulna, as well as of the head and neck of the radius. 

This case shows also how widely we may err in our diagnosis, mis- 
taking a very extensive injury for a single limited fracture. It pre- 
sented to me also a phenomenon which it may be well to mention. 
After having assuaged the inflammation and lessened very much the 
suppuration, I perceived protruding from the wound a sort of blackish 
fungus, which bled at the slightest touch. I was at first uncertain 
as to its nature, but at last ascertained that it was simply an un- 
organised clot. It came away, and was followed successively by 
several others which in their turn also fell off, each time with a slight 
hemorrhage. At the autopsy I found the joint full of black clots, 
extending downward for an inch around the crushed bones. No 
vessel of any size had been ruptured, but this incessant hemorrhage 
seemed to have been an oozing from the spongy tissue of the bone. 

On the whole, compound comminuted fracture is always a very 
grave lesion, and often requires amputation, either primarily or 
secondarily; but we should avoid resorting to this prematurely. In 
one case, in which the joint was so opened that the finger could be 
passed through and feel the artery pulsating in front, Sir A. Cooper 
proposed amputation ; but the patient refused to submit to it, and 
his arm was actually saved. Kirkbride has also related two instances 
of recovery from severe compound fractures of this kind.* 

We must in these, as in all other compound fractures, remove any 
splinters which are loose, or but slightly adherent; seek to allay in- 
flammation, and if at all possible to obtain union of the wound by 
the first intention; if this cannot be done, free openings should be 
made for the escape of the pus. The most absolute rest is necessary ; 
in order to which the forearm should be kept flexed at a right angle, 
by means of the same apparatus as in fractures of both condyles; 
but cicatrisation once completed, we should immediately begin passive 
motion of the joint. 

* Am. Journ. of the Med. Sciences, Aug., 1834, p. 312. 



CHAPTER XIII. 

FRACTURES OF THE BONES OF THE FOREARM. 

These fractures are certainly very common, since, even excluding 
those of the olecranon, they comprise more than an eighth of the 
whole number treated at the Hotel-Dieu. Lonsdale goes so far as 
to say that they are the most frequent of all ; an evident error, which 
may be explained by the mode of treatment of the different fractures 
at the Middlesex Hospital ; those of the upper extremity being made 
out-door cases, and not limited as to number ; while those of the 
lower extremity being received into the institution, the number of 
admissions is necessarily regulated by that of the beds. I shall recur 
to this question in connection with fractures of the lower extremity 
of the radius. 

We shall study successively fractures of both bones, or fractures 
of the forearm, properly so called ; fractures of the ulna ; and frac- 
tures of the radius, which are subdivided into those of the shaft and 
those of the lower extremity of the bone. But it will not be unin 
teresting to cast a glance at their relative frequency and the predis- 
positions affecting each. 

Fractures of the radius alone are more common than those of the 
forearm, and these again are more common than those of the ulna. 

If we inquire into the influence of age, we find fractures of the 
forearm and of the radius quite common in infancy, while they 
steadily increase in more advanced life ; those of the ulna on the 
contrary hardly occur at all except in fully developed subjects; of 
twenty-nine cases, twenty-eight were above the age of twenty, and 
the remaining one was over ten. 

As to sex, of fractures of the ulna four-fifths occur in men ; twenty- 
three to six ; of those of the forearm and radius, only three-fifths ; 
sixty-seven to forty, and ninety-five to sixty-five. But as regards 
the last two, the proportion of the sexes varies curiously in the dif- 
ferent ages. 

In the forearm they are in equal number from two to fifteen years; 
from fifteen to twenty, there are eighteen men to one woman ; from 
twenty to forty-five, the number of men just doubles that of the 
women; after forty-five, the women regain their equality, and even 
go a little beyond it, being twenty-two to nineteen. 
(470) 



A TREATISE ON FRACTURES. 471 

In the radius, the number of male cases to female is ten to one in 
infancy ; between fifteen and twenty it is fifteen to one. Thus up to 
twenty years of age this fracture is almost exclusively masculine. 
From twenty to forty-five, it affects women in pretty large numbers ; 
twenty-two in a total of seventy two, or nearly the same proportion as 
in fractures of the forearm. But after forty-five, another change 
occurs, and the fracture displays a marked preference for the female 
sex; there being but twenty men to forty-one women. 

The influence of the seasons is almost as varied. Fractures of the 
ulna are as frequent in summer as in winter ; those of the forearm 
are more common in winter, while those of the radius abound more 
in summer. But these latter, in winter, affect women a little more 
frequently than men ; while in summer the number of male cases 
more than doubles that of the females, being sixty to twenty-six. 



§ I. — Fractures of the Forearm. 

The causes of these fractures are almost always direct, such as a 
severe blow, a fall in which the forearm strikes against something, 
the passage of a carriage-wheel, etc. Sometimes the fracture is in- 
direct, as from a fall on the hand ; but this is quite rare. Lastly, 
I have had to treat one fracture occurring under circumstances which 
were quite exceptional. One of the insane patients at Bicetre, 
thirty-eight years old, otherwise sound and robust, was digging in 
the fields, when in trying to lift a shovelful of earth he heard two 
distinct cracks in the right forearm, and was immediately disabled 
from work ; the next day I made out a fracture of the radius about 
the middle, and one of the ulna about an inch lower down, with 
considerable displacement. This was therefore a fracture from 
muscular action; of which I have hitherto met with no other 
instance. 

These fractures present some varieties, according to their seat and 
direction. In general they occur at about the middle of the fore- 
arm; more rarely in the lower third; those of the upper third are 
the most unusual of all. Sometimes the two bones are broken at 
the same, sometimes at different levels ; and in the latter case I have 
alwavs seen the radius broken higher up than the ulna. (See Figs. 
51 and 52.) 

I have elsewhere stated that partial fractures, in young patients, 
were more frequently met with in the forearm than in any other 
region; they are almost always the result of a fall on the palm or 
back of the hand. It would be needless to repeat what was given of 
their history. (See page 53 et %eq.) 

These fractures when complete present generally wide serrations, 
without marked obliquity; although they may be somewhat oblique. 



472 A TREATISE ON FRACTURES. 

They may also be comminuted, or perhaps divide each bone at two 
different points; thus Desault saw a forearm broken, by the passage 
of a cart-wheel, at its middle and lower portions; it presented six 
fragments, distinct one from the other. 

The symptoms of these injuries are in the first place those of frac- 
ture generally: pain, loss of power, mobility, crepitation, etc.; but 
the displacement alone calls for special study. 

Sometimes in children there is no appreciable displacement; and 
I have seen one such case also in an adult; but this is rare, and 
Boyer even asserts that displacement is always present. 

These displacements are of several kinds. Sometimes both the 
lower fragments incline to the upper so as to make an angle salient 
anteriorly or posteriorly, when the forearm seems to be bent at .the 
seat of injury. More commonly the inclination is in the other direc- 
tion, the fragments of the radius approaching those of the ulna, and 
the interosseous space being narrowed or even obliterated. It is 
rare, when this occurs, for the fractured surfaces not to be more or 
less separated; and hence a displacement in the direction of the 
thickness, in virtue of which the fragments move upon one another 
in various directions. Displacement by rotation may also be pro- 
duced by putting the hand into complete pronation or supination 
without first insuring coaptation; but especially does it almost always 
accompany overlapping, by a mechanism which will be mentioned 
directly. Lastly, overlapping occurs here, as elsewhere, under two 
conditions : either the fragments, being divided obliquely, are drawn 
upon by the muscles, or, in a nearly transverse serrated fracture, 
they have been completely disjoined; in this case, the overlapping, 
according to what I have seen, is more marked than in the former. 
I have dissected a recent fracture in which the shortening amounted 
to nearly two-thirds of an inch; and there is in the Muse'e Dupuy- 
tren a specimen in which it cannot be less than two and two-thirds 
inches. 

These different displacements may be variously combined; Figs. 
51 and 52 give a very accurate idea of them. 

The fracture represented in Fig. 52 is at about the middle, and at 
the same level in both bones. As far as we can judge from the cal- 
lus, it was oblique downward and backward in the radius, downward 
and outward in the ulna. Consequently, the lower fragment of the 
radius has passed up some millimetres in front of the other, the point 
of which is seen to project backward, and the lower fragment of the 
ulna has likewise passed up on the inner side of the upper. This 
upper fragment of the ulna is therefore in a manner interposed be- 
tween the two lower fragments, keeping them apart, so that the inter- 
osseous space between them has lost nothing in width; while above 
this space has been greatly reduced, and in one point even oblite- 
rated, by the approximation of the upper fragments. There was, 



A TREATISE OX FRACTURES. 473 

however, no fusion of the two hones, and the motions of pronation 
and supination could still he executed, though to a very limited ex- 
tent. Lastly, in the specimen, the two lower fragments formed with 
the two upper an angle salient backward, which could not be shown 
in the drawing. 

Here then is slight overlapping in an oblique fracture ; Fig. 52 
displays greater displacement in a nearly transverse fracture, with 
other peculiarities quite worthy of notice. 

The fracture in this case has occurred in the lower third of the 
radius, and in the lower fourth of the ulna. The inferior fragment 
of the ulna has passed up backward, that of the radius forward; 
which could only take place through marked rotary displacement, 
the lower part of the arm nearly approaching pronation, while the 
upper part still remained nearly supinated. From this rotation it 
follows that the inferior fragment of the radius, carried in front of 
the superior fragment of the ulna, is separated by it from the infe- 
rior fragment of the latter bone; so that below the interosseous space 
is almost entirely preserved, while higher up it has been considerably 
reduced by the approximation of the two upper fragments. 

By what mechanism are the two lower fragments thus thrown one 
forward and the other backward? Probably from the external vio- 
lence placing the forearm in semipronation, and then after causing 
the fracture giving the lower fragments a movement of pronation, 
so as to bring that of the radius forward and that of the ulna back- 
ward. I have had an opportunity of ascertaining, in a recent frac- 
ture of this kind, the essential cause of the fragments remaining in 
their new relations, which also prevents, in the majority of cases, 
the occurrence of any very considerable displacement; it is found 
in the overlapping of the two portions of the interosseous ligament, 
which serve to keep apart all the fragments; the upper portion of 
the ulna slipping in front of the lower portion of this ligament, and 
the upper portion of the radius behind it. 

But sometimes the rotation takes place in the opposite direction, 
as if the lower portion of the forearm had been placed in supination 
by the fracturing cause; and then it is the lower portion of the ulna 
which comes forward, while that of the radius goes backward. Such 
was the case in my insane patient, whose fracture seemed to be the 
result of muscular action; when the subsidence of the swelling en- 
abled me to ascertain the relations of the fragments, I found them 
in the first place deranged in the manner stated; but moreover, what 
is curious, the two upper fragments seemed interposed between the 
two lower ones, thus separating them by more than the normal dis- 
tance. To give some idea of this, the width of the forearm, taken 
between the two bones above the fracture, was not quite two inches, 
while below the fracture it was about two and a half. Just such a 
displacement, except that the overlapping is much more considerable, 



474 A TREATISE ON FRACTURES. 

may be seen in the Muse'e Dupuytren, (No. 93;) it has been repre- 
sented in the atlas of that museum, so that I cannot myself give a 
drawing of it. 

It seems, then, in the first place, that when the overlapping in- 
volves both bones at once, the upper fragments always approach one 
another; and moreover, that according as the lower fragments have 
been twisted into pronation or supination, they maintain their natural 
degree of separation or undergo an increase of it. 

I said, when the overlapping involves both bones, the radius may 
be fractured with overlapping by a fall on the hand, the force then 
exhausting itself in breaking the ulna, which presents little or no 
displacement. I have had such a fracture represented in Fig. 53 ; 
the radius is broken about two inches above the joint; its lower frag- 
ment is carried slightly backward, but very much inward, and the 
ulna is bent so as to meet it. Hence we find the articular surface 
of the radius drawn upward, and a very great deviation outward of 
the hand. The ulna projects very strongly above the carpal bones, 
and its styloid process, further removed from the pisiform bone than 
usual, is separated from it by a sesamoid bone developed in the sub- 
stance of the ligament. 

When there is little or no displacement, the course of the fracture 
is very simple, and union occurs in about thirty days. But when 
the displacement is considerable, or perhaps when the external vio- 
lence has been very severe, we often see very great inflammatory 
swelling, and in no fracture is gangrene so likely to occur from the 
pressure of apparatus. Sometimes the mortification attacks the 
points directly compressed; sometimes phlyctense appear first be- 
tween the fingers or on the hand. Bichat confesses that this ac- 
cident happened quite often in Desault's practice. If immediately 
attended to, the gangrene may be limited to the points primarily 
affected; but more than once, in limbs too completely enveloped by 
bandages, it has pursued its insidious march until amputation was the 
only resource. 

Aside from this danger, every fracture of the forearm with dis- 
placement is a lesion productive of serious consequences. Too often 
it involves loss of the movements of pronation and supination; I have 
seen several examples of this unpleasant result, which is especially 
to be apprehended when the bones are broken at the same level. It 
is not even necessary that the fragments should be in contact with 
one another ; the collections of the Faculte [de Medecine] afford two 
instances of soldering together of the two bones at a distance, by 
bony prolongations traversing the interosseous space.* In more 
favorable cases the bones are not soldered together, but the motions 
of pronation and supination remain more or less limited ; which may 

* J. Cloquet, art. Avant-bras in the Diet, de M6d. en 30 vols. 



A TREATISE ON FRACTURES. 475 

be explained both by the narrowing of the interspace, and by the 
crossing of the fragments. Lastly, I have twice witnessed even 
more deplorable results; the motions of pronation and supination 
being lost, doubtless by union of each fragment with the opposite 
piece of the other bone, and the solidity of the forearm being de- 
stroyed by the non-adherence of the upper and lower fragments. 

The prognosis should be based on these views, not however for- 
getting the influence of skilful or unskilful treatment. The diagnosis 
is established by crepitation, deformity, and shortening, and in any 
case whatever by preternatural mobility at the seat of fracture. 

The treatment is very simple when there is little or no displace- 
ment ; in fact no reduction is needful in such cases. So also when the 
fragments are only inclined toward one another, extension is entirely 
useless ; the surgeon should correct any angle that they may form ; 
when they are so approximated as to lessen the interosseous space, he 
should try to push them outward in the manner which will be stated 
directly. In other words, extension is unnecessary unless there is 
great lateral displacement, or overlapping. 

In these latter cases, the forearm and fingers should be semi- 
flexed; an assistant, grasping the arm near the elbow, should make 
counter-extension, while another takes hold of the wrist and makes 
extension. These two assistants are enough, if the surgeon is called 
a few hours after the accident ; if not, we must employ more, making 
them pull upon handkerchiefs fastened around the elbow and wrist, 
and we must not shrink from using great force. Hippocrates com- 
plains that the surgeons of his time did not use enough; and we 
should err greatly in believing with Boyer that the reduction is al- 
ways easy. The position of the limb is not a matter of indifference ; 
we should pull first in the direction into which the fracture has 
thrown it ; and when the broken ends are brought to the same level, 
or even drawn somewhat apart, we should bring the lower fragments 
into supination if they have been pronated, and vice versd. 

Having thus put the fragments end to end, we must think of re- 
storing the interosseous space. In order to do this, we are directed 
to hold the forearm in a state of semipronation, and then, applying 
the thumbs on the dorsal face of the limb, to bear with the fingers of 
both hands on the palmar face, trying by suitable manipulations to 
push aside the muscles and thus remove the fragments of the radius 
from those of the ulna. 

I doubt if any one has ever entirely succeeded by this method, 
which I have almost always seen to fail completely. When the fore- 
arm leaves the supine position, the radius tends to cross oyer the 
ulna, and the fingers cannot sufficiently penetrate the interosseous 
space. Supination is therefore to be preferred. 

The same question comes up in regard to the application of the 
apparatus, and has been mooted ever since the earliest times. Hip- 



476 A TREATISE ON FRACTURES. 

poorates states that the surgeons of his clay kept the forearm in the 
sapinated posture; he disapproves of this plan. His authority pre- 
vailed so completely, that in the sixteenth century A. Pare*, after 
finding fault with semipronation, and proving the advantages of 
supination, changed his ground when he found that it was opposed 
to that taken by Hippocrates. I had thought myself the first, after 
Pare, to return to supination ; but I have found that Lonsdale was 
before me, he having recommended it since 1832; and still more 
recently it has been stoutly defended by M. Bidart.* 

The only reasons in favor of semipronation are, that it keeps all 
the muscles equally relaxed, and is most convenient for the patient; 
they have been amply sufficient to induce surgeons to prefer as a 
general rule a middle position for fractured limbs. But these general 
views should yield here, as elsewhere, before special indications. Now 
in the forearm, when the two bones approach one another so as to 
narrow the interosseous space, it is of essential importance to restore 
this space, if we would preserve the movements of pronation and 
supination, and the convenience of the patient should be sacrificed to 
his ultimate advantage. Lonsdale has added another argument; he 
thinks that the upper fragment of the radius often remains supinated, 
and that even in bringing the lower one into contact with it, if we 
keep the forearm in the middle position, we only perpetuate the 
rotary displacement of one of the fragments upon the other ; which 
may explain why, after treatment on the usual plan, it is mainly 
supination that is impaired. This view does not seem to me based 
upon positive facts, and needs further proof. I would therefore 
limit the value of supination to those cases only in which the inter- 
osseous space is compromised ; in all others, semipronation affords as 
many advantages and fewer inconveniences. 

[If any one will take an articulated skeleton of the arm, and try 
these different positions of the forearm, it may easily be seen that it 
is only in semipronation, or when the thumb is turned directly up- 
ward, that the radius and ulna are parallel. "With this idea, and 
not with that of relaxation of the muscles, or the comfort of the pa- 
tient, this position is rigorously adopted in all fractures of the fore- 
arm in the Pennsylvania Hospital, and by very many surgeons in 
the United States ; and the plan is so uniformly successful that it is 
only where some unusual complication is present that perfect use of 
the limb is not regained. It may perhaps be said that cases of de- 
formity after fracture of both bones of the forearm are of very rare 
occurrence.] 

The forms of apparatus proposed have also varied. From the 
time of Hippocrates down to the eighteenth century, surgeons used 

* Lonsdale, London Medical Gazette, vol. ix, p. 910; Malgaigne, Anat* 
Chirurgicale, tome ii ; and Gazette des Hopitaux, 1839, p. 437 ; Bidart, Jour- 
nal de Chirurgie, 1845, p. 199. 



A TREATISE ON FRACTURES. 477 

merely simple splints, without at all attempting to restore the inter- 
space between the bones. J. L. Petit first conceived of putting two 
thick compresses, one in front and the other behind, so as to press 
the muscles in between the bones, and separate the fragments; un- 
fortunately, he begun by the application of a roller, securing the 
compresses by a second, so that their action was entirely nullified. 

This plan however embodied an idea which was taken up and im- 
proved upon by Pouteau. His apparatus consisted of two rolls of linen 
or tow, as long as the forearm, and at least an inch thick. These two 
rolls were placed directly upon the skin, fastened by a loose circular 
bandage, and then over each was laid a small board or wooden splint, 
a little wider than the forearm. The spaces between the edges of 
these splints were filled with linen or tow, and over all were applied 
circular turns of a bandage, much more tightly drawn than the 
former one.* 

Desault, who would seem to have been unacquainted with Pouteau's 
work, employed a nearly similar apparatus, substituting graduated 
compresses for the rolls of linen or tow, and aiding the two first 
splints by two others, arranged along the outer and inner borders of 
the forearm. Boyer, rejecting these latter as useless, thus readopted 
exactly the means used by Pouteau, except that he retained the gra- 
duated compresses ; but he insisted on these being thick enough to 
make the dorso-palmar diameter of the limb greater than the radio- 
cubital. Such is the apparatus which is still most generally employed 
in France, with the slight modification of dropping the first bandage, 
and applying the splints directly over the compresses. 

It would be useless to describe all the modifications of this appa- 
ratus, differing from it only in the form and material of the splints, 
in the use of straps instead of bandages, or in the solidifying of 
these latter with starch or dextrine. The only two improvements 
sufficiently marked to merit attention are those of Amesbury, who 
sought to hold the two bones apart by means of convex splints, and 
of M. Nelaton, who substituted for the graduated compresses pieces 
of cork, in the following manner. 

He had to treat a fracture of the forearm in which the radius pre- 
sented a middle fragment which could hardly be retained in place. 
He commenced by applying a dextrinated bandage loosely to the 
hand and forearm ; after which a long cork was laid over each inter- 
osseous space, opposite the middle fragment of the radius, and fixed 
there by several turns of a roller, pressing it in between the bones ; 
when the apparatus became dry, the corks were removed, but left a 
longitudinal depression in front and behind sufficient to maintain 
accurate reduction. M. Ne'laton remarks that in place of putting 

* Pouteau, (Euvres Posthumes, tome ii, p. 261. 






478 A TREATISE ON FRACTURES. 

the corks above the dextrinated bandage, we might apply them to 
greater advantage directly upon the skin, covering them with a roller. 

The first objection I have to bring against all these forms of appa- 
ratus is that they are applied in a position unfavorable to the end 
sought. I repeat, and I would beg all surgeons to prove it upon the 
skeleton, supination is indispensable to the complete separation of 
the fragments. 

Most of them are open to a second objection, in regard to the 
length of the rolls or graduated compresses used. By making them 
as long as the forearm, we give them above and below two points 
d'appui upon the extremities of the bones, preventing them from 
sinking as they should into the interosseous space at the middle. A 
third inconvenience results from the want of parallelism of the two 
bones, the upper extremity of the radius being on a plane anterior 
to that of the ulna; so that the compresses, resting equally at all 
points, tend to press the upper fragment of the radius backward, and 
that of the ulna forward. 

It would not suffice even to reduce them to the exact length of the 
interosseous space ; for this space becomes very narrow above and 
below, and hence either the compresses being forced in equally along 
its whole length would produce too much widening of it at its centre, 
or, what is more likely, they would fill it neither above nor below, 
and hence only partially at the centre. I have therefore long been 
convinced that the graduated compresses should be applied only at 
the seat of fracture, and that their length should not be more than 
one or two inches. M. Nelaton's apparatus is the only one in which 
this idea is adopted. Besides the advantages already mentioned, 
there is another which is not unimportant ; M. Lenoir, inquiring into 
the cause of the frequency of gangrene in these fractures, attributes 
it to the pressure of the apparatus upon the radial and ulnar arte- 
ries, which lie directly upon the bone at the lower part of the fore- 
arm;* and this pressure is avoided as much as possible by limiting 
the action of the compresses to the vicinity of the fracture. 

Lastly, we should fit also the width of the compresses to that of 
the interosseous space ; this is greatest toward the 1 middle ; above 
and below it narrows greatly, and the compresses, if a little too wide, 
bear upon the bone on each side without having any effect on the in- 
terval between them. 

I have hitherto spoken only of graduated compresses, which I 
prefer in practice. The rolls used by Pouteau would doubtless an- 
swer the same purpose ; as for M. Nelaton's corks, I should have 
some fear of their injuring the skin by their hardness. 

The splints should be of nearly the same width as the forearm, so 
as to prevent the bandage from pressing over the bones ; above they 

* Lenoir, Thlse inaug., Paris, 1833, No. 315. p. 19. 



A TREATISE ON FRACTURES. 479 

should reach only to the olecranon behind, and to the bend of the 
elbow in front ; and below they should come as far as the wrist. To 
keep them in place, I prefer to any other means three strips of lead- 
plaster, which are not apt to become relaxed, and which leave the 
skin exposed between them. Lastly, the forearm should be put into 
a sling, embracing the elbow and lightly supporting the hand ; it 
should not be brought in front of the chest, but simply carried at the 
side, the elbow a little behind and the hand pointing forward ; and 
the ends of the sling should pass one in front and the other behind 
the body, to meet in a knot over the sound shoulder. 

Such is the apparatus which I prefer when there is danger of nar- 
rowing of the interosseous space, and especially in cases with over- 
lapping, whether this has been reduced or is irreducible. If the 
fragments have not become entirely disconnected, and if the inter- 
osseous space be but slightly encroached upon, semipronation is more 
convenient, and may be properly chosen. There is one other case 
in which it is very suitable, namely, when the injury of the soft 
parts, or the crushing of the bones, is so great as to render the fusion 
of the two bones inevitable ; it would then indeed be far better for 
the patient to have the forearm in the middle position than in supi- 
nation. 

When we put the forearm into semipronation, we support it in the 
same way in a sling, but we should apply its palmar face against the 
front of the chest, the thumb upward and the little finger downward. 
But this position involves a new danger, which was accurately 
studied by Hippocrates, and the reality of which the specimens in 
our museums show but too plainly. If the sling is so arranged as to 
press chiefly at the middle, the elbow and hand will fall somewhat, 
and the fragments will form an angle salient upward, i.e., toward the 
radial side. If, on the contrary, the hand and elbow are too much 
supported, the fragments will make an angle salient downward, or 
toward the ulnar side. The first of these deformities is more com- 
mon than the second ; there are in the Musee Dupuytren three spe- 
cimens of fracture of the ulna, which have plainly belonged to frac- 
tures of the forearm, and in which the fragments form angles toward 
the radial side varying from 135° to more than 150°. 

In view of these facts, Hippocrates enjoins making the sling bear 
equally upon all points of the forearm, including the wrist. But 
even then the weight of the hand may tilt up the lower fragment ; 
whence it should also be supported in the sling. Desault did not 
trust to this, and added two lateral splints to the ordinary apparatus. 
I own that I would not myself trust to a sling ; in even the simplest 
. I much prefer putting the forearm into a pasteboard trough 
reaching from the elbow down to the roots of the fingers ; and in 
case of need, I should not hesitate to place a solid splint along the 
ulna and metacarpus. 



480 A TREATISE ON FRACTURES. 

[The difficulty just spoken of is entirely done away with by the 
plan adopted in the United States, viz., the use of two straight 
splints reaching from above the elbow to the ends of the fingers. 
These are applied to the anterior and posterior faces of the forearm 
in the semiprone position, being previously carefully padded as ad- 
vised in the text ; and the pressure of the sling being exerted only 
upon their edges, cannot of course influence the position of the 
fragments.] 

When the fracture is complicated with a wound or with inflamma- 
tory swelling, it is best that the patient should keep his bed, the 
forearm being placed on a pillow, and suitable topical remedies ap- 
plied. By reason of the weight of the hand and the slight resist- 
ance of the pillow, the forearm, at first semipronated, soon passes 
into complete pronation ; and this result is so common that many 
surgeons do not even try to avoid it, but put the hand at once in the 
prone position. This position is not mentioned in the books, although 
very often met with in practice, and presents no advantages to com- 
pensate for its inconvenience and danger. We ought in these cases 
to insure at least a middle position * and this I do by applying to the 
palmar face of the forearm a thick cushion like those used in frac- 
tures of the leg, so that the ulnar border and the cushion together 
form so wide a surface on the pillow that the pronation of the forearm 
becomes impossible. The pillow should moreover be so solid as not 
to allow of the hand sinking into it, and thus forming an angle at 
the seat of fracture ; it is safest to give it firmness by putting a wide 
board beneath it. 

§ II. — Fractures of the Ulna. 

Fracture of the ulna generally occurs from direct violence, such 
particularly as a blow warded off with the forearm, which is instinc- 
tively pronated, and the ulna thus put immediately in the way. 
Being by its position and relations removed from the wrist, the ulna 
would seem likely to escape the action of any indirect cause. 
M. Voisin has, however, published a case, hitherto unique, of frac- 
ture of the ulna from a fall on the palm of the hand ; this lesion 
presented, moreover, an arrangement as singular as its cause ; as 
well as could be ascertained during life, there had been merely a de- 
tachment of a longitudinal splinter from the articular facette of the 
bone ; there was no displacement, and the fracture was unrecognised 
for several days, when M. Voisiri having conceived the idea of pro- 
nating the forearm, grasped the radius firmly with the left hand, and 
the lower extremity of the ulna with the right ; in this way he easily 
detected very evident crepitation and mobility.* 

* Gazette Mtdicale, 1833, p. 24. 



A TREATISE ON FRACTURES. 481 

The ulna may be broken at any point in its length; but it is gene- 
rally the lower third or the middle portion which is affected in pre- 
ference. 

This fracture often occurs without either displacement or crepita- 
tion ; and then the circumstance of a blow, the swelling, and the 
persistent local pain, are the only grounds upon which we can base 
the diagnosis. "When there is displacement, it is always the lower 
fragment which, following the impulse given it by the blow, passes 
backward, forward, or to the radial side, or in two of these directions 
at once ; the upper fragment is too solidly articulated with the hu- 
merus to yield, unless in case of a luxation or a sprain. 

The displacement varies in extent ; sometimes it is slight, and 
hardly perceptible ; sometimes it is easily recognised, although the 
fragments may still be in contact ; sometimes, lastly, it is complete, 
when they are entirely separated. In all these cases we find con- 
stantly the end of the upper fragment projecting beneath the skin, 
inward, backward, or more rarely forward, according to the direction 
in which the lower fragment has been driven. To this incontestable 
sign of fracture are nearly always added mobility and crepitation ; 
to obtain these we should first fix the radius either in pronation or in 
supination, and then grasp the upper fragment with one hand, while 
with the other we seek to move the lower one backward and forward. 

The prognosis of this fracture is rarely serious; in fact the dis- 
placement is rarely so extensive as to compromise the movements of 
pronation and supination. Still, slight as it may be, it is exces- 
sively difficult of reduction, since we have no purchase for our ex- 
tension; and when the lower fragment has been driven strongly 
toward the radius, unless it can be replaced, the rotary movement of 
the forearm may be destroyed; of this M. Bidart cites an example.* 

In order to effect reduction, we are advised to draw upon the 
hand turned toward the radial side; a plan more plausible in theory 
than efficient in practice. All our efforts should tend to separate 
the lower fragment from the radius, the manoeuvre required being 
the same as in fractures of the forearm. As to other displacements, 
we may diminish them by pressure; but time is generally lost in en- 
deavoring to accomplish complete reduction. 

The apparatus is very simple when there is little or no displace- 
ment; the forearm should be kept semipronated with two plain 
splints, in order to prevent the motions of the two bones upon one 
another, and suspended in an ordinary sling. We may very pro- 
perly substitute for these two splints a starched or dextrinated band- 
age; or in the very simplest cases we may merely apply a hollow 
pasteboard splint, making even the sling unnecessary. 

But when the displacement is considerable, and threatens to 

* See my Journal de Chirurgie, 1845, p. 200. 
31 



482 A TREATISE ON FRACTURES. 

diminish the interosseous space, we should resort to supination and 
all the apparatus for fracture of the forearm. Supination is even 
sometimes necessary, simply to insure the contact and union of the 
fragments. 

M. Fleury has published a curious case of fracture of the ulna 
treated by semipronation, in which the displaced fragments had not 
united. He could only keep them in contact by fixing the forearm 
in supination; and as he wished to use a dextrinated bandage, he 
used, to maintain supination till the apparatus dried, a very simple 
means pointed out in my Anatomic Chirurgicale, viz., two small 
transverse splints properly fastened a little above the wrist. The 
apparatus being removed at the end of forty days, the ulna was 
found to be solid, and the limb, although at first very stiff, ultimately 
recovered its movements entirely.* 

Compound fractures of the ulna are much less serious than those 
of the forearm, since the radius acts as a splint, and of itself suf- 
fices to hinder mobility or displacement. M. A. Berard had to 
treat a comminuted fracture of the lower fourth of the ulna, with 
division of the muscles before and behind it, and of the ulnar artery 
and nerve; he tied both ends of the artery, dressed the wound, 
placed the forearm first upon cushions and afterwards in the ordi- 
nary apparatus for fracture of both bones, and succeeded in ob- 
taining, at the end of sixty-eight days, complete consolidation and 
cicatrisation, t 



§ III. — Fractures of the Shaft of the Radius. 

The radius alone may be broken at any point in its length ; but 
setting aside fractures of its lower extremity, those of its shaft are 
less frequent than those of the shaft of the ulna. Sir A. Cooper 
has raised some doubts as to the reality of fractures of the neck of 
the radius. I once believed that I had several times seen it in children 
carelessly lifted by the wrist; but experiments on the dead body have 
shown me that in these cases there was rather subluxation than frac- 
ture. I shall again refer to this interesting point in connection with 
dislocations of the radius. 

Fractures of the body of the bone are produced sometimes by 
direct causes, but oftener by falls on the hand. Van Nierop has 
cited a case in which muscular action seemed to play the most im- 
portant part; it was that of a woman aged 30, who having wrung 
out two large sheets, felt a very sharp pain in the forearm; he de- 
tected a fracture in the lower third of the radius.J 



* Journal de Ghirurgie, 1845, p. 314. 
t Gazette Mtdicale, 1833, p. 403. 
% Gazette des Hopitaux, 1844, p. 224. 



A TREATISE ON FRACTURES. 483 

[In April, 1856, I saw a case in the Baltimore Infirmary, under 
the care of Dr. Miltonberger, in which the symptoms of fracture of 
the radius high up were very well marked ; the man had felt some- 
thing give way while he was pulling violently in driving a pair of 
young horses.] 

The symptoms are variable. Sometimes the fragments remain in- 
terlocked; and then the only signs of the fracture are, the pain 
developed locally by pressure or by any movement, and perhaps 
bending of the bone at a certain point under strong pressure. In 
other cases the external violence drives in toward the ulna either 
one fragment, as in Fig. 50, or both, as in Fig. 53. In the latter, 
indeed, the ulna is fractured also, but since its fragments have re- 
mained in position, the fact does not affect the displacement in the 
case of the radius. Lastly, when a blow falls directly on the dorsal 
or palmar face of the bone, one of the fragments may be driven 
either in front or behind the other. In all cases, besides the pain, 
we may by the touch recognise the existence and character of the 
displacement; and by fixing the upper fragment with the fingers, 
and then pronating and supinating the hand, we may easily elicit 
distinct crepitation. 

But there is one other form of displacement, thought by Boyer to 
be impossible, and which occurs under very different circumstances: 
I allude to overlapping. Sometimes it is only partial, so to speak, 
and shortens only the outer edge of the bone; as when it results 
from the lower fragment being driven in toward the ulna. Fig. 50 
shows this condition extremely well. The inner part of the articular 
surface of the radius has remained almost in its place, while the sty- 
loid process has been drawn up to the level of that of the ulna, than 
which it is notably lower in the normal state of things. This kind 
of overlapping by inclination is naturally quite limited, since the in- 
clination itself is limited by the contact of the lower fragment with 
the ulna; and for the same reason it is less in proportion as the 
fracture has occurred higher up, and greater in proportion as the 
lower fragment, being shorter, describes a larger arc. But some- 
times there is added to this a direct overlapping, the lower fragment 
slipping upward along the ulna, which remains luxated inward, as 
seen in Fig. 53. Lastly, the overlapping may be still more marked, 
the luxated ulna protruding through the integuments; the fracture 
of the radius is then either comminuted or multiple ; but this belongs 
more especially to the subject of luxations of the ulna. 

It will be seen that in cases where the overlapping is slightest, 
there is spreading, or diastasis, of the lower articulation of the two 
bones; and that hence the wrist is somewhat widened, the distance 
between the two styloid processes being increased, as was stated by 
Pouteau. But this author conceived that depression of the frag- 
ments of the radius toward the ulna should increase the length of 



484 A TREATISE ON FRACTURES. 

the radius, by effacing its natural curvature ;* an idea which, although 
very specious theoretically, has never been proven by practice. 

The diagnosis commonly offers very little difficulty. Desault was 
the first to point out, as a possible source of error, the crackling of 
the tendons of the extensors of the thumb in case of inflammation 
of their sheath, which might be mistaken for the crepitation of a 
fracture by an inexperienced surgeon ; but besides that this sound 
is very different from bony crepitus, it only occurs when those mus- 
cles are put into action, and not when motion is imparted merely to 
the bone. 

The prognosis, in properly treated cases, is quite favorable. 
Thirty days will suffice for union to occur. 

The treatment is based on nearly the same indications as that of 
fractures of the forearm. When however the lower fragment is 
driven in toward the ulna, besides the methods already pointed out 
for restoring the interosseous space, the integrity of the ulna affords 
us another, namely, traction on the hand in a state of extreme ab- 
duction. We thus overcome the spreading of the two bones at the 
wrist-joint; we bring the styloid process inward, and consequently 
downward, and thus necessarily tend to carry outward the end of 
the upper fragment. Actual overlapping, with luxation of the ulna, 
would require direct extension to be previously made. 

Reduction once accomplished, it is generally sufficient to arrange 
along the interosseous space graduated compresses, supported by 
splints ; I need not dwell upon the different forms of apparatus, 
which are the same as those described for fractures of the forearm. 
I must however allude here to a contrivance of M. Baudens, intended 
especially for fractures of the radius. It consists of a nearly semi- 
elliptical steel spring, with each end rounded so as to press into the 
interosseous space before and behind. In order to guard against 
excoriation, we first apply two little splints about an inch and a half 
long and an inch wide, properly padded, upon which the two ends of 
the instrument may press. As this does not insure the immobility 
of the limb, M. Baudens employs also a box, with loops and cushions ; 
making a heavy and complicated apparatus. f The two splints an- 
swer our purpose much better. 

In more difficult cases, it may become necessary to keep the hand 
forcibly abducted, and perhaps even to make permanent extension. 
But the appliances for meeting this double indication having been 
mainly devised for fractures of the lower extremity of the bone, I 
shall postpone their description to the next section. 

* Pouteau, Me'm. contenant quelques rtflex. sur les fract. de V avant-bras, 
etc. ; (Euvres Posth., tome ii, p. 251. 
f Gazette des Hopttaux, 1844, p. 505. 



A TREATISE OX FRACTURES. 485 



§ IV. — Fractures of the Lower Extremity of the Radius. 

These fractures, hardly noticed by the ancients, but described with 
some care by Pouteau and Desault, have been especially studied in 
our own times by Sir A. Cooper, Dupuytren, MM. Goyrand, Diday, 
and Voillemier ; and I have myself likewise devoted some attention 
to their investigation.* 

The first question which arises is as to their frequency. M. Goy- 
rand has asserted that they are to all other fractures put together 
as one to two ; Dupuytren gives them in this respect, if not the first, 
at least the second or third rank. But these exaggerated state- 
ments are set aside by facts. Without arguing from my figures de- 
rived from the Hotel-Dieu, which upon this point are not sufficiently 
exact, I have before me a table of the cases treated in one ward 
by Dupuytren in the year 1818 : of 81 fractures there were but 
four of the radius ; in 1827, a corresponding table shows sixteen out 
of 109 ; in 1828, five out of 110 ; in January, 1830, sixteen out of 
101 ; and putting these four proportions together, we have a total of 
forty-one out of 401, — one-tenth. In the last year of my service 
at the Hopital Saint- Antoine, from January 1 to August 1, 1844, 
among sixty-seven fractures, I met with seven of the lower extremity 
of the radius, — a ratio nearly the same as above. 

I pass over the influences of sex and of age here, as they were 
sufficiently dwelt upon at the beginning of this chapter. 

This fracture is rarely due to direct violence; although M. Hu- 
blier has communicated to the Academie de Medecine the case of a 
young girl, who, having had her wrist caught between a wall and a 
carriage-pole, had a transverse fracture of the lower end of the ra- 
dius, with a vertical fracture dividing the lower fragment into two 
parts. f But the most frequent cause is a fall on the palm of the 
hand, and next to this a fall on the back of the hand; of fourteen 
fractures observed at the Hotel-Dieu in January, 1830, three were 
induced in the manner last mentioned. 

By what mechanism do these falls give rise to fractures of the 
lower end of the radius? It may be alleged first that the bone, 
being caught between two forces, the weight of the body acting 
on its upper end and the resistance of the ground on the lower, 
tends to give way where it is weakest, namely, at the point where 
the compact tissue ends; and this theory seems to be established 

* Pouteau. op. at.; Goyrand, Premier Mtmoire; Gazette Med., 1832, p. 
664; Deuxiemt Memoire, Jowrn. Hebdomad., Feb., 1836; Malgaigne, Memoire 
surles lux. du poignet, etc.: Gazette Me'd., 1832. p. 730; Diday, Archiv. Ge'n. 
de Medecine, 1837, tome xiii, p. 141; and Voillemier, ibid., 1842, tome xiii, 
p. 261. 

t Archiv. Ge'n. de MCdecine, tome xx, p. 291. 



486 A TREATISE ON FRACTURES. 

by the following experiments. M. Ndlaton amputated the fore- 
arm of a dead body at the elbow, and resected the olecranon; 
then, applying the palm of the hand upon a solid surface, the fore- 
arm being kept vertical, he struck a heavy blow upon the upper ends 
of the two bones. The wrist cracked, and became deformed, and 
dissection revealed a simple transverse fracture at the extremity of 
the radius, the lower fragment being thrown backward. I make no 
doubt that in a very large number of cases this is the mechanism of 
the fracture. Sometimes again it seems as though the bone, without 
bending, were crushed between the two forces, as in a vice; M. Voil- 
lemier has given a representation of a case in which the upper frag- 
ment, rounded at its edges, was driven nearly three inches into the 
spongy tissue of the lower, and had broken the articulating portion 
into four pieces. 

Lastly, there are cases, perhaps more numerous than would be 
supposed, in which the wrist does not touch the ground, and the bone 
does not yield to the two forces acting in contrary directions, as 
before described ; but by an exaggerated flexion of the hand forward 
or backward, the extremity of the radius, following the movement, 
is torn away from the rest of the bone. M. Bouchet was the first to 
establish this idea ; in trying to dislocate the wrist in the dead sub- 
ject, he only succeeded in producing fractures of the lower extremity 
of the radius, sometimes with other lesions, and especially with frac- 
ture of the styloid process of the ulna.* M. Yoillemier had two 
opportunities of observing analogous fractures in the living subject; 
in one case a man had fallen upon the lower half of the hand, not 
upon its "heel;" in the other the patient had not fallen at all, but a 
comrade had forced his wrist into immoderate flexion; here the con- 
ditions were exactly the same as in M. Bouchet's experiments. 

We see from the foregoing that this fracture may exist by itself, 
or complicated with another entering the joint, or with crushing of 
the lower fragment and its articular face, or lastly, with a tearing 
away of the styloid process of the ulna. It remains for us to study 
the disposition of the principal fracture, and the nature of its dif- 
ferent displacements. 

One word first as to their seat. According to Dupuytren this may 
be three to six lines, or even an inch, from the articular surface. 
Sir A. Cooper states that it is generally an inch above the styloid 
process; M. Nelaton, about half an inch above the anterior edge 
of the bone. There may doubtless be slight variations, owing to the 
age and stature of the subjects, which influence the length of the 
radius; or from the crushing of the lower fragment, or the length 
of the serrations on its upper edge. But upon dissection, the prin- 
cipal division of the bone has always seemed to me to be at nearly 

* Bouchet, TJiZse sur les lux. du poignet, Paris, July, 1834. 



A TREATISE ON FRACTURES. 487 

the same point, namely, just where the compact tissue of the shaft 
gives place to the true spongy tissue of the end. And as it takes a 
transverse direction, the fracture is more or less distant from the 
joint, according to the point where we examine it ; thus in Fig. 54, 
the fracture, if examined in front and on the inner side, is not more 
than one-third of an inch from the articulation ; examined behind, 
Fig. 55, the interval is about twice as great, and if measured upward 
from the styloid process, it amounts to nearly a full inch. 

I have said that the fracture is generally transverse ; M. Voille- 
mier was the first to prove, contrary to the statements of preceding 
authors, that there does not exist an instance in which it is oblique ; 
and I would add that for my own part I know of no oblique frac- 
tures in this region except such as pass into the joint, which will 
come up again in connection with luxations of the wrist. [At the 
end of the present chapter will be found a note upon this subject.] 
But because the fracture divides the bone transversely, it is not ne- 
cessarily any more even; we see in Figs. 54 and 55, numerous ser- 
rations about the edges of a recent fracture; and in Fig. 56 they 
are still more clearly shown. M. Voillemier has represented them 
more than a third of an inch in length ; and in one of his specimens, 
one of the serrations, detached at its base, is transformed into a 
splinter. 

Sometimes, and indeed not very rarely, there is no appreciable 
displacement. The patient feels severe pains in the wrist, increased 
by pressure or by motion; and except a slight swelling, perceived 
especially in front, there is no deformity ; so that we might be led to 
think the injury a mere sprain. But if pressure is made directly 
over the line of the articulation, little or no pain is caused, while 
about an inch above this the pain is very severe ; and we obtain a 
pathognomonic sign by putting the thumb behind the supposed seat 
of fracture, and trying to bend the bone at this point so as to make 
an angle forward; a comparison of the two wrists will now place the 
matter beyond a doubt. 

We must not, however, assume, because there is no appreciable 
displacement, that there is none in reality. The specimen repre- 
sented in Figs. 54, 55 and 56 was taken from a woman of seventy, 
who died on the fourteenth day after her accident, of pneumonia; 
this had prevented the reparative process, so that the fracture was 
in appearance a very recent one. The upper fragment is seen to be 
moved on the other about one-thirtieth of an inch forward, and about 
one-eighth or one-sixth of an inch inward. The swelling, however, 
entirely masked this slight displacement; there was no crepitation, 
nor mobility from side to side; and M. Maisonneuve, who sent me 
the account and the specimen, only arrived at the diagnosis by bend- 
ing the forearm in the manner mentioned. The injury was produced 
by a fall on the wrist ; the periosteum was entirely torn across in 



488 A TREATISE ON FRACTURES. 

front, but posteriorly it remained intact ; which explains the greater 
facility of separating the fragments, and of bending the forearm to 
a right angle, in front than behind. 

In other cases this angle exists already, serving of itself to point 
out the fracture, even when the swelling would prevent our detecting 
the slight prominence formed posteriorly by the lower fragment ; this 
I have seen in a good many instances. We must not suppose that 
the angle thus visible at the palmar face of the forearm is formed by 
the fragments themselves; their line of separation occurs just where 
the anterior surface of the bone ceases to be vertical, by curving for- 
ward. When we try to bend the limb at this part, we hardly do 
anything but restore the natural concavity of the bone; but the soft 
parts lodged in the interspace then necessarily make an abnormal 
prominence in front; and hence I say that the angle is formed by 
the forearm, and not by the radius itself. 

In an another variety, which seems also to be quite common, the 
lower fragment projects backward and the upper forward, so that 
the forearm and hand nearly resemble, according to M. Yelpeau's 
apt comparison, the back of a silver fork ; a superficial examination 
might lead us to suspect a luxation backward of the wrist. It is 
hardly the case then that the lower fragment makes an angle with 
the other; the articular surface of the radius has only sustained a 
rotation backward to an almost imperceptible degree; the styloid 
process remains almost exactly at its normal level, and the relations 
of the hand with the ulna are not sensibly altered. The projection 
forward of the upper fragment, however, is much less marked than 
that of the lower one backward, owing partly to the inclination of 
the latter, slight as it may be, and partly to the penetration of the 
latter into the spongy tissue of the former; in one of M. Voille- 
mier's figures (No. 3, pi. ii,) these circumstances are accurately ren- 
dered. The backward displacement of the lower fragment must be 
very considerable in order for us to perceive the projection forward 
of the lower end of the ulna, a sort of slight luxation which will be 
again mentioned in due time. 

Lastly, we meet with cases in which in the first place the lower 
fragment projects backward, giving the wrist an appearance to be 
presently described; but moreover, the hand is drawn toward the 
radial side, and the lower end of the ulna makes a more or less 
marked prominence inward. The mechanism of this displacement 
is hitherto unexplained. Pouteau thought that the lower fragment 
was drawn inward by the pronator quadratus, so as to lessen the 
interosseous space and tilt outward the styloid process. But M. Voil- 
lemier justly observes that there is no interosseous space at the level 
of the fracture; he ascribes the displacement to the great force sus- 
tained in the fall by the outer half of the wrist, and to the deeper 
penetration of the upper fragment on the side corresponding to the 



A TREATISE ON FRACTURES. 489 

styloid process. I would not deny the possibility of this being the 
mechanism; but it is not what my observations so far have shown 
me; in my opinion, the displacement in question depends essentially 
on a tilting backward and upward of the lower fragment, the upper 
one being deeply penetrated posteriorly, and the two remaining 
merely in contact in front. This view is completely illustrated in 
Figs. 57, 58 and 59. 

We see first in Fig. 57 the anterior faces of the two fragments to 
be nearly in the same vertical plane, while posteriorly the lower one 
projects about one-quarter of an inch; the styloid process is on the 
same level with the anterior edge of the articular surface, but much 
below the posterior. All this is made still clearer in Figs. 58 
and 59. 

These two figures represent a specimen removed from an old man 
at Bicetre, whose fracture, one of long standing, was unreduced. 
Fig. 58 shows the posterior aspect of the radius and ulna; the sty- 
loid process of the radius is nearly on the same plane with the ante- 
rior edge of the articular face, and with the styloid process of the 
ulna itself. The posterior edge is, on the contrary, remarkably ele- 
vated, so that the articular face looks downward and backward, 
whereas in its normal state it looks downward and forward. In Fig. 
59 the radius has been sawed vertically, and we have a still better 
view, showing at once the flattening of the anterior surface, the pro- 
jection backward of the lower fragment, and the singular distortion 
of the articular face. Thus the styloid process is not thrown out- 
ward ; it has only described, along with the whole lower fragment, 
an arc of a circle, carrying it up backward, and making its apex 
actually point as much backward as downward. This arc could not 
be described without some derangement of the radio-ulnar articula- 
tion, the cavity at the side of the radius offering obliquely to the 
head of the ulna, which continues horizontal; whence arises an alto- 
gether peculiar separation of the two articular surfaces, a new spe- 
cies of diastasis, very different from that which sometimes occurs in 
fractures of the shaft of the radius. The stretched ligaments have 
pulled upon and torn away the styloid process of the ulna; and 
lastly, this bone, passing down posteriorly a little below the radius, 
loses its connection with the carpus, which maintains its radial arti- 
culation. There are cases in which the ulna is actually dislocated, 
either forward or backward; I shall postpone the consideration of 
these until we take up the subject of luxations. 

Let me say lastly a few words concerning displacement forward, 
which is very rare; I have never had an opportunity of observing 
it. I have quoted in my Memoir 'e sur les luxations du poignet, a case 
given by M. Cruveilhier as an example of radio-carpal luxation, in 
which there was merely a fracture of the radius with displacement 
forward of the lower fragment; and with the drawing only before 



490 A TREATISE ON FRACTURES. 

me, I presumed that there had been a separation of the epiphysis, 
this being thrown en masse in front of the radius. The complete 
turning forward of the articular face authorised such a conjecture; 
but in a case in which this was much less marked, M. Voillemier 
showed that the anterior wall of the shaft had penetrated the spongy 
tissue of the lower fragment, exactly as the posterior wall does in 
cases of displacement backward. 

This penetration is unmistakable in the preparation, if we divide 
the radius by a vertical section from before backward ; and I cannot 
account for its having escaped the notice of M. Diday. In Fig. 59 
we see the compact wall of the diaphysis driven nearly an inch into 
the spongy tissue ; but we must here take notice that this great pene- 
tration is more apparent than real. All above the projecting angle 
of the lower fragment belongs to the uniting callus, so that the actual 
penetration is reduced to a few millimetres. This is clearly shown 
in Fig. 57, representing a fracture not entirely consolidated; all the 
posterior portion of the callus having been removed by maceration, 
we see exposed the projecting angle of the lower fragment, and the 
space between it and the diaphysis ; this space was filled with the 
callus, some traces of which are found about two-thirds of an inch 
higher up. 

Such are the principal aspects of fracture of the lower extremity 
of the radius, whether during life or upon dissection. I may add 
that it is very often complicated with fracture of the styloid process 
of the ulna; but this generally retains its place, or is at the most 
drawn slightly outward. (See Fig. 58.) There remains now, to com- 
plete the subject, the study of a few special symptoms. 

Crepitation is generally wanting; which seems to me owing to the 
absence of mobility from side to side. Since, in fact, the fragments 
do not move except by forming an angle, there is no perceptible 
rubbing together of them, and hence no crepitation; but this appears 
at once when there is mobility, and especially when there are 
splinters. 

The deformity is often masked by the swelling. It is well to recol- 
lect that the projection of the lower fragment backward, due to its 
penetration by the other, is generally more masked than that of the 
latter forward ; for this is what has deceived some observers into an 
over-estimate of the obliquity. This displacement has also the effect, 
by increasing the antero-posterior diameter, of giving a cylindrical 
form to the lower portion of the forearm, and thus leads sometimes 
to the erroneous idea that the transverse diameter is diminished. 

Such diminution of the transverse diameter may, however, actu 
ally occur, by a mechanism hitherto unexplained, as seen in Fig. 2; 
the upper fragment approaches the ulna, while the lower maintains 
its position. Pouteau likewise pointed out a widening of the wrist 
between the styloid processes; I have already mentioned how such a 



A TREATISE ON FRACTURES. 491 

widening may result from a diastasis of the radio-ulnar articulation ; 
it is still more marked in cases of crushing of the articular end of 
the radius, which naturally throws its styloid process outward. But 
these two symptoms are rare, never well-marked, and detected with 
difficulty during life, on account of the thickness and swelling of the 
soft parts. 

Lastly, a word must be said as to this swelling, which presents a 
particularly remarkable aspect on the anterior face of the forearm. 
J. L. Petit ascribes it to sanguineous, oedematous, or inflammatory 
infiltration in the areolar tissue over the pronator quadratus; Ber- 
trandi, to the tearing of the muscles and their compression by the 
fasciae. Pouteau advances the idea that it is due to contraction of 
the pronator quadratus; Sir A. Cooper seems to attribute it to the 
projection of the fragments themselves. I think, for my own part, 
that the chief source of the swelling is in the first place from extra- 
vasation of blood, and subsequently from inflammation, occurring in 
the cellular tissue and in the sheaths of the tendons; which explains 
its predilection for the anterior surface. 

The consequences of these fractures, when they are misunderstood 
or improperly treated, are quite serious. Deformity of the forearm, 
impairment of pronation and supination, as well as of flexion of the 
wrist and hand, and feebleness of the ringers in prehension; long- 
persistent swelling and pain; sometimes obstinate stiffening of the 
joint, or even inflammation and its consequences, may be mentioned. 
Lastly, M. Goyrand has seen permanent contraction of the fingers 
as a consequence of this fracture. 

The diagnosis is now rendered so easy, by slight study of the re- 
lations of the styloid processes and the level of the osseous promi- 
nences, by the seat of the pain, and lastly by the abnormal bending 
of the bone at the point of injury, that it is no longer excusable for 
any surgeon to err in regard to it. We should bear in mind, how- 
ever, that it has long been liable to be mistaken for a dislocation or 
a sprain, and that Dupuytren first succeeded in correcting this error. 
I shall recur to the differential diagnosis in treating of the above in- 
juries. The slight fracture of the styloid process of the ulna often 
goes unrecognised ; it may be suspected from the pain caused by 
pressure over it. 

The prognosis is extremely favorable when the fracture is recog- 
nised in time, and when there is only a displacement of the lower 
fragment backward. But if the styloid process is carried up a good 
deal above its natural position, and if the hand has departed a good 
deal from the ulna, deviating outward, it will be very difficult even 
to lessen this abduction, and almost impossible to overcome it en- 
tirely. Deformity is likewise inevitable when the articular end of 
the bone is crushed. 

The treatment varies according as there is or is not displacement, 



492 A TREATISE ON FRACTURES. 



and if there is any, according to its nature and extent. If there is 
none, two splints, or a dextrinated bandage, will be sufficient ; but 
when it does exist, it gives rise to indications for the fulfilment of 
which numerous means have been devised. The three objects hitherto 
aimed at are (1) the restoration of the interosseous space; (2) the 
correction of the displacement backward (or forward) of the inferior 
fragment ; (3) the correction of the abduction of the hand, by bring- 
ing the styloid process down to its natural level. 

First Indication ; to restore the Interosseous Space.— -This is what 
was sought by Pouteau with his rolls of linen, by Desault with his 
graduated compresses, and by.M. Baudens with his steel spring. 
Now, as there is no interosseous space at the level of the lower frag- 
ment ; as the upper fragment is only very rarely carried inward, and 
even then does not sensibly compromise the interosseous space ; as, 
finally, this slight displacement, very difficult of detection in the 
living subject, would probably be still more difficult to overcome, this 
first indication falls to the ground, and need not be further dwelt 
upon. 

Second Indication ; to correct the Displacement backward. — The 
reduction of this displacement, when it exists by itself, requires only 
moderate extension ; one assistant draws upon the hand, while an- 
other holds the forearm, and the surgeon, putting the fingers of both 
hands over the angle or fragment in front, pushes forward with the 
thumbs the posterior fragment ; in most cases even extension is un- 
necessary. It now remains to keep up the reduction thus made. 

Sir A. Cooper was the first to treat of this. He applied two small 
pads, one in front over the wrist, and the other behind over the back 
of the hand, binding them on with a roller, and making pressure 
through them by means of two splints reaching from the elbow to 
the end of the metacarpus. 

M. Goyrand's first apparatus somewhat resembled that of Sir A. 
Cooper. It consisted of two small pads, the anterior of which, an 
inch in length, was placed just above the bend of the wrist, while 
the posterior came down over the metacarpus. So also the two 
splints came just as far as the ends of these pads. Subsequently 
M. Goyrand improved his anterior pad by making it thicker above 
than below, so as to exert less pressure on the anterior edge of the 
articular surface of the radius. 

It is too evident that this anterior pad, descending just as far as 
the wrist, tends to press the lower fragment backward, while all its 
action in this direction should bear upon the upper fragment. As 
for the posterior pad, it needs only to act on the lower fragment, 
without extending over the back of the hand ; in fact, there is an 
actual inconvenience in thus prolonging it, from its holding the hand 
in an unnatural position, and hence stretching the extensor muscles, 
and favoring stiffening of the joints. I have therefore for many 






A TREATISE ON FRACTURES. 493 

years employed the following simple apparatus, and with constant 
success.* 

With two compresses, from eight to sixteen times doubled, I make 
two pads three fingers'-breadths long, and as wide as the forearm; I 
arrange one transversely, just over the anterior fragment, and the 
other over the posterior fragment, taking care that it never extends 
down so far as to prevent the habitual flexion of the wrist backward. 
I then apply in front and behind two properly padded splints, mak- 
ing them press firmly upon the two pads, and not allowing either of 
them to go beyond the wrist ; the anterior one alone should reach a 
little beyond the corresponding pad, by which its extremity is kept 
too far removed from the wrist for it to do any harm; this slight pro- 
longation is necessary to insure the action of the posterior splint. 
The whole is kept in place either by a roller made to cover the splints 
in their entire extent, and if necessary stiffened with albumen or dex- 
trine, or by three strips of lead-plaster, between which the skin is 
left exposed to view. The forearm is finally suspended in a sling, in 
the middle position ; that is to say, resting on its ulnar border. 

Third Indication ; to correct the Abduction of the Hand. — This 
was first pointed out by Cline ; and the mode proposed by him for 
its fulfilment has at least the merit of great simplicity. The fore- 
arm, placed between two splints, was hung in a sling which reached 
no farther than the wrist ; and the hand hung by its own weight to- 
ward the ulnar side, or in other words, in the position of adduction. 

Dupuytren sought the same end, but by more energetic means. 
To the ordinary apparatus for fractures of the forearm he added his 
ulnar splint, made of a bit of iron an inch in width, greatly curved 
in the arc of a circle opposite the wrist, and furnished with knobs on 
its concave surface. This splint was applied along the ulna, being 
held off from the wrist by means of a small cushion of oat-bran, or 
by thick compresses, and fixed with a roller. Then the ulnar border 
of the hand was fitted to its convexity, so as to be brought into for- 
cible adduction, and maintained thus by a bandage, or by a mere 
loop ; care being taken, however, to protect the index-finger by a 
small pad or compress, lest the pressure of the loop should produce 
excoriation. The knobs on the concave surface of the splint were 
intended to fasten each turn of the bandage at the proper height. 
The attempt has been made to substitute for this iron splint wooden 
ones, which should first cover the forearm in the ordinary way, and 
which at the wrist should bend sharply inward, not by their surfaces, 
but by their edges. M. Blandin has proposed this kind of splint, 
which was, however, previously known. f 

* See my Memoir, already quoted, and the Gazette des Hopitaux, Jan. 15, 
1839. 

f Gazette des Hopitaux, Oct. 8, 1836. These splints had been mentioned in 
the Gazette Medicate, April 9, 1836, p. 234. 



494 A TREATISE ON FRACTURES. 

M. Dumesnil has devised an apparatus more easily to be procured, 
since it requires only ordinary splints and bandages. The two 
splints, one and a half to two inches in width, should reach from 
above the elbow to beyond the finger-ends. They are confined by 
means of a roller extending from the wrist to the bend of the elbow. 
"There, in place of carrying the roller around the entire circumfer- 
ence of the arm, two or three figure-of-8 turns are made to embrace 
the upper ends of the splints ; after which the bandage is exhausted 
in complete turns." The first roller being thus disposed of, a small 
bandage is applied by its middle portion over the radial border of 
the hand, at the level of the metacarpal bone of the thumb ; its two 
ends are brought over to the ulnar border, being passed between the 
hand and the splints ; and each end being again brought over the 
outer face of the corresponding splint, the two are fastened together 
by a double knot over the radial edge of one or the other splint. 
The middle of this band serves to adduct the hand, taking its point 
d'appui at the ulnar edge of both splints, which represent, as it 
were, pulleys.* 

These contrivances having been but partially successful, permanent 
extension was proposed. The idea occurred simultaneously, about 
ten years ago, to M. Godin and M. Diday; they devised for the pur- 
pose some plans, of which there remains only the bare mention by 
the latter ; and the only two apparatuses at present known are those 
of M. Huguier and M. Velpeau. 

M. Huguier, considering the fact that the hand and forearm pre- 
sent two cones connected by their summits, sought in the first place 
to take his points d'appui at the widest parts of these cones. He 
therefore covers the wrist and hand with a sort of glove, by means 
of a bandage, the turns of which hold in place four loops, two in 
front and two behind; these loops are brought down over the fin- 
gers, and meant for making extension. The forearm is now covered 
by a soft dry bandage ; above this are placed two graduated com- 
presses before and behind over the interosseous space, but ending 
about two-thirds of an inch above the wrist, so as not to bear upon 
the prominences of the radius. Lastly come two splints, differing in 
three points from those in common use ; in the first place their edges 
are notched, to prevent their slipping beneath the bandage confining 
them, and to secure counter-extension by keeping them up in their 
places : secondly, they reach beyond the ends of the fingers, and 
have at their extremities upright tenons for the attachment of the 
extending loops ; and thirdly, they should be cut out at their upper 
ends, so as to receive other splints applied to the arm itself. Thus, 
we put in front of the arm a pasteboard splint bent at the elbow, so 
as to come down on the forearm, and over this latter a wooden splint 

* Gazette des ffopitaux, Dec. 21, 1841. 



A TREATISE ON FRACTURES. 495 

reaching up only to the bend of the elbow. On the posterior face of 
the arm Ave put another wooden splint, reaching a little below the 
olecranon. In this way we give the forearm splints a more solid 
point cVappui than is afforded by the tissues of the forearm, which 
soon become excoriated from the combined effect of pressure and 
want of action. 

M. Velpeau fixes in a nearly similar manner two bits of bandage 
in the shape of loops, to make extension ; but for counter-extension 
he applies to the elbow a sort of boot-top, by which is confined a 
loop; both these preliminary bandages are imbued with dextrine, to 
give them firmness. It only remains to draw these loops tight, and 
fasten them to the two ends of a splint, somewhat longer than the 
forearm, and terminating in a perpendicular stem.* 

Without dwelling further upon the comparative value of these two 
methods, I should fear that either of them would be too painful to be 
borne ; and M. Diday informs us that in the trials he made of them, 
the suffering caused by making extension was so great that he was 
obliged to abandon them. But the strongest objection lies in the 
fact that the overlapping itself is in most instances merely due to the 
tilting backward of the lower fragment ; whence in fact the only in- 
dication is to push this forward. If to this tilting backward there is 
joined a real separation outward of the styloid process, with projec- 
tion inward of the ulna, two new indications arise, namely, to push 
the latter outward, and at the same time to replace the former in- 
ward. Permanent extension can do nothing here; the sling invented 
by Cline is useless ; splints with curved edges, and M. Dumesnil's 
apparatus, have the serious defect of not pressing the ulna toward 
the radius. Dupuytren's ulnar splint is the only one which would 
fulfil this indication, but Dupuytren, and all who have followed him, 
have missed their aim by acting upon the hand itself in making the 
adduction ; so that the two forces which should approximate the ra- 
dius and ulna not being directly opposed to one another, their due 
effect is lost, and the ulna remains always more than naturally pro- 
minent. It should be borne in mind that the hand gets its improper 
position by following the inferior fragment, and that it is this frag- 
ment which needs restoration. I think therefore that we should be 
more certain of success with two lateral splints, acting like the dorsal 
and palmar splints in displacement backward ; the one on the radial 
side should bear on the lower fragment by means of a pad, so as to 
press it inward ; the other in the same manner should push outward 
the lower end of the ulna, while the hand should be left to its own 
gravity outside of the sling, according to the practice of Cline and 
of Sir A. Cooper. 

Whatever apparatus we may have recourse to, it is important for 

* Gazette dee Hopiiaux, 1842, p. 27. 



496 A TREATISE ON FRACTURES. 

us to guard against stiffening of the wrist and fingers, which is a 
very common sequel of this fracture. For this reason, I do not 
allow the splints to reach beyond the first row of the carpal bones, 
but leave the hand free and completely relaxed, the metacarpus flexed 
backward, and the fingers forward; in order thus to be able to im- 
press upon all the joints moderate motion, which may be done without 
the slightest difficulty. 

I remove the apparatus at the eighteenth to the twenty-second day, 
to ascertain the condition of things, and to remedy any displacement 
which may have occurred ; after this I do not touch it until the thir- 
tieth clay, when I leave the limb entirely at liberty. I would repeat 
that by pursuing this method I have always found this fracture one 
of the easiest to cure, without stiffening, deformity, or the slightest 
impairment of the functions of the limb; excepting, of course, in 
those very grave cases complicated with actual luxation of the ulna, 
to which reference will be made hereafter. 

Before concluding this subject, I would say a few words concerning 
separation of the epiphysis of the radius, which forms perhaps the 
most frequent instance of that class of injuries. M. J. Cloquet as- 
certained it by dissection in a child of twelve; M. Roux in a child, 
age not given; Johnston, in a young man of eighteen;* and lastly, 
M. Voillemier produced it with great facility in the dead body, by 
making forcible flexion or extension of the wrist, not only in very 
young subjects, but in a robust man of twenty-four. The causes, 
symptoms, and treatment are identical with those of the veritable 
fracture ; but we have reason to suspect this separation rather than 
fracture in patients under twenty years of age. 

[In 1840, Dr. John Rhea Barton, of Philadelphia, published, in 
Hays' American Journal of the Medical Sciences , an account of a 
form of fracture in which the styloid process of the radius is chipped 
off, and the articular face of the bone of course divided. It is nearly 
always the result of indirect violence, is of very frequent occurrence, 
and entails consequences so immediately traceable to the fracture 
itself as to make this the proper place for its description. The hand 
is pronated and flexed on the forearm by its own weight as well as 
by the action of the flexor muscles ; and the fragment is thus as it 
were squeezed upward into a deformity at the back of the wrist. 
At the same time the muscles of the thumb, and the flexor carpi 
radialis, draw the radial side of the hand upward, causing the ulna 
to project, the carpal bones departing from it. To these causes of 
deformity there is sooner or later added effusion into the carpal bursae, 
or into the joint, or both. (This effusion ensues also upon fractures 
more nearly transverse, when the prolongation of the synovial mem- 

* J. Cloquet, Did. de Mtd. en 30 vols., art. Fractures de V avant-bras ; Eoux, 
These de M. Galand, Paris, July, 1834; Johnston, Bulletin de la Soc. Anato- 
mique, 1839, p. 189. 



A TREATISE OX FRACTURES. 



497 




brane upward between the radius and ulna is injured.) For obvious 
reasons the distortion is greater than in the transverse fracture 
higher up, described by Colles. The line of separation may often 
be clearly traced with the fingers ; its direction is seen in the annexed 
drawing, which Dr. Henry H. Smith 
has kindly allowed me to make from 
a specimen in his collection. An 
analogous preparation is in the pos- 
session of Dr. Edward Peace, of this 
city. (In Dr. Smith's preparation a 
small portion of the lower end of the 
ulna is also separated. No history 
of the case can be obtained.) 

In the treatment of this injury, 
Dr. Barton advised the use of two 
compresses, a dorsal and a palmar, 
so arranged as to press the fragments 
into place, and of two splints, like- 
wise dorsal and palmar, reaching 
from the elbow to the ends of the 
fingers; he also recommended that 
passive motion should be made after 
the third or fourth day. 

In 1852, Dr. Henry Bond, of Philadelphia, proposed a new form 
of splint for this fracture. (See the Am. Journ. of the Med. Sc, 1852, 
p. 566.) It is easily made by cutting out a thin piece of board, 
such as the lid of a cigar-box, in the shape of the sound limb, so as 
to reach from the elbow to the second 
joint of the fingers. This piece of 
board is now turned over, and a block 
of soft wood of suitable size and shape 
is so fitted to it as to be grasped by 
the fingers of the injured hand. A 
roller, or a piece of cotton cloth, is 
now made to envelope the splint, to 
which may be added sides, of leather 
or pasteboard. (See Cut.) The splint 
thus made being well padded, the fore- 
arm laid in it, a roller is applied, 
and the whole placed in a sling, the 
thumb being carefully kept upward. 
Passive motion may be made very 
early, and in a great many cases a 
cure is effected without the slightest ' 
trace of deformity. Some caution 
must however be observed in leaving 

32 




498 A TREATISE ON FRACTURES. 

off the splint, as if this be done too early the deformity is sure to 
recur; five weeks is the very shortest time allowable. 

The advantages ascribed to this method by Dr. Bond are realised 
constantly in the practice of very many American surgeons. They 
are as follows: — 

(1.) The inclination of the hand toward the ulnar side, as in 
M. Nelaton's attelle cubitale. 

(2.) Relaxing the muscles, by keeping the wrist in its most usual 
position, — flexion backward ; keeping the fingers in a state of com- 
fortable flexion; and if stiffening is unavoidable, preserving some 
degree of usefulness of the member. 

(3.) Keeping the whole apparatus firm, by pinning the roller to 
the muslin envelope of the wooden splint. 

This splint may be used with advantage in other fractures of the 
forearm also, either with or without the addition of a dorsal com- 
press or splint. Dr. Robert P. Harris, of this city, tells me that he 
has modified the palmar block, making it convex from side to side 
above, so as to fit better to the palm of the hand; he has also de- 
rived advantage from the use of a thin pad filling up the hollow at 
the radial side of the front of the forearm, just above the wrist.] 



CHAPTER XIV. 

FRACTURES OF THE BONES OF THE HAND. 

Fractures of the hand present in the first place this remarkable 
peculiarity, that they occur almost exclusively in men; we shall see 
in studying them separately how rare they are in women. 

They all have also this point of resemblance : that very often, and 
perhaps most commonly, they result from direct causes of such a 
violent character that not only the bones but the soft parts are bruised 
and lacerated, and so injured as to make the fracture a mere epiphe- 
nomenon. Such is apt to be the case when the hand is crushed by 
a carriage-wheel, caught in a machine, or wounded by gunshot, and 
especially when a firearm bursts in the hand. I shall not dwell on 
these grave injuries in which amputation is commonly necessary, and 
which belong rather among complicated [or compound] fractures. 
"We have here to study only simple fractures, or those with such 
slight complications as do not materially modify the indications for 
treatment. 

Fractures of the hand may be classed under three heads : those 
of the carpal bones ; those of the metacarpal bones ; and those of 
the phalanges. 

§ I. — Fractures of the Carpal Bones. 

These fractures are extremely rare unless we include among them 
cases of crushing, and are almost always due to direct causes. It is 
indeed matter of surprise that falls on the hand, from which so many 
fractures of the radius result, so seldom give rise to the injury in 
question. The carpus does not however always escape. M. Bouchet, 
in making forcible flexion and extension of the hand in the dead 
body, found among the other lesions one or more fractures of the 
bones of the wrist ; M. J. Cloquet met with them in two autopsies 
upon persons who had sustained falls on the wrist ; and M. Jarjavay 
lately detected a fracture of the scaphoid from a similar cause.* 

In M. J. Cloquet's two cases, the swelling of the soft parts had 

* Bouchet, op. cit., Paris, July, 1834; J. Cloquet, art. Main, in the Did. de 
M6d. en 30 vols. ; Jarjavay, These inaug., Paris, 1846, p. 25. 

(499) 



500 A TREATISE ON FRACTURES. 

prevented the detection of the fractures during life; and it would 
seem to have been so in M. Jarjavay's patient also. It is therefore 
to be presumed that most commonly the fracture is revealed only by 
the crepitation ; but care is required lest we mistake its seat, and 
improperly suppose it to affect the radius. The treatment should 
consist essentially in keeping the wrist at perfect rest, with the pre- 
caution however of making passive motion from time to time, to 
prevent stiffening of the joint. 



§ II. — Fractures of the Metacarpal Bones, 

These fractures are not frequent, as may be seen from their small 
number, — sixteen, — in our total of cases at the Hotel-Dieu. 

They are met with almost exclusively in males; of the sixteen 
cases at the Hotel-Dieu, but one was a woman; I have myself ob- 
served five cases in men, and only one in a woman ; and it will be 
seen that all the cases quoted in this article have been likewise, with 
one exception, in men. 

Adults seem also specially liable to this injury ; the sixteen pa- 
tients at the Hotel-Dieu ranged from seventeen to fifty-three years. 
Other periods of life are not however exempt; I have treated two 
such cases in men of sixty-three and seventy respectively, and have 
seen one in a little girl of five ; but in this last case there was pro- 
bably a separation of the epiphysis. 

Boyer has stated that several of the bones are generally involved 
at once. This is entirely contrary to my own experience; and I 
would add that of the sixteen cases treated at the Hotel-Dieu, ten 
only of which are precisely described, nine were limited to a single 
bone ; in the tenth both the second and the third bone were con- 
cerned. It is proper however to draw a distinction between cases of 
great crushing of the hand, in which commonly several of the bones 
are broken, and ordinary cases, which are not apt to involve more 
than one. 

Are the five metacarpal bones all equally exposed to fracture? 
Boyer, Delpech, and Chelius, say that the fifth is the one oftenest 
broken; Samuel Cooper puts the first in the same rank, while ac- 
cording to M. A. BeVard it is less frequently affected than any other. 
The question is difficult of solution, in view of the small number of 
cases. Of the nine single fractures at the Hotel-Dieu, the first bone 
of the row was the one concerned in five, the second in two, the 
third in one, and the fifth also in one. I have myself, however, three 
times seen fracture of the fourth. The two specimens represented 
in Figs. 60 and 61 belong respectively to the second and third 
bones. 

These fractures may result from either direct or indirect violence. 



A TREATISE OX FRACTURES. 501 

The direct causes are in the first place all such as give rise to the 
severe injuries of the hand just alluded to; but many simple and un- 
complicated fractures may also be produced in the same way, and 
the study of these causes is not without interest. Sometimes a foreign 
body strikes against the bone. Dupuytren related in his lectures the 
case of a student, who in assisting to let off some fireworks T\as struck 
on the hand by the stick of a rocket, and had one of the metacarpal 
bones broken. Sometimes there is direct pressure on the bone; as 
in a man whose hand was caught between a wall and a carriage-pole, 
and pulled it away with fracture of the second and third metacarpals. 
More commonly it is the hand which strikes against something ; as 
in a woman seen by Murat, who had broken her fifth metacarpal 
by a fall on the ulnar side of the hand ; and in a carter in whom 
M. J. Cloquet observed a fracture of the fourth and fifth, caused by 
striking a back-handed blow upon his horse's head. Lastly, there is 
sometimes a double impulse, the hand moving in one direction and 
the external object in the other, as when the hand receives the jar 
of the end of a stick with which one strikes violently against the 
ground or some other resisting surface; Sanson claims to have seen 
several such cases.* 

Such are the direct causes, acting sometimes on a single bone, 
sometimes upon several at once. The indirect causes hardly ever 
affect more than one bone at a time; and they seem to act chiefly 
upon the third, on account of its being longer than the rest. They 
present also some varieties. Most commonly the injury is the result 
of a fall, the fist being closed, upon the prominent head of the bone; 
such a case is recorded in the Dictionnaire des Sciences Medicates; 
M. J. Cloquet and M. Sabatierf each saw a similar one; in all three 
the fracture was at the middle of the third bone. Much more rarely, 
the bone is broken by a fall on the end of the extended middle- 
finger; Lonsdale cites a case of the kind. In other instances the 
cause is a violent blow with the fist, planted by the patient, the hand 
being supinated and the head of the bone striking first; Lonsdale 
saw such a case ; the mechanism is the same as in falls, the bone 
being between two forces which tend to .bring together its two ex- 
tremities, and giving way in the middle. The mechanism was quite 
different in the unique case reported by Velpeau; here a water- 
carrier had had his fore and middle fingers pulled upon by a carter 
with such force as to break the third metacarpal bone. Lastly, 
Dupuytren mentions an instance which so far stands alone, in con- 
tract to all those cases in which the bone tends to flex forward, thus 
almost necessarily giving rise to an angle at the back of the hand; 

* See the article headed Mttacarpe, {fractures,) in the Dictionnaire des 
Sciences Mtdicales ; and that headed Main, [fractures,) by M. A. Berard, in 
the Diet. ()< .'./• i u 30 vols. 

f Journal Compl£mentatre, tome xl. p. 188. 



502 A TREATISE ON FRACTURES. 

here the fracture was caused by the bone being forcibly bent back- 
ward. Two men were trying which could pull back the other's wrist; 
their fingers were interlocked, the heads of the metacarpal bones 
directly opposed to one another, and the phalanges bent back and 
pressing firmly against the dorsum of the hand; the stronger of the 
two broke his adversary's third metacarpal bone. 

But are none of the other bones of the metacarpus ever exposed 
to indirect fracture ? We cannot say so theoretically, and for my 
own part I have seen three cases, involving, what is perhaps re- 
markable, the fourth bone in each instance. In two of these cases 
the patients had fallen on the closed hand, and consequently on the 
head of the fourth metacarpal bone ; in the remaining one the cause 
was somewhat different. A cooper was unloading a cask of wine on 
the wharf at Bercy; on account of the cold he had a glove on his 
right hand. This glove was caught by the sharp end of one of the 
hoops, and the cask rolling on, his hand was caught for a moment in 
supination, in such a way that the head of the fourth metacarpal 
bone bore against the edge of a curbstone, while the cask went over 
the back of his thumb. The bone gave way in its upper third, owing 
to the forcible bending, the fragments forming an angle salient 
backward.* 

These fractures may be serrated, oblique, or splintered. The 
obliquity may probably assume any direction; but I have hitherto 
met with it only downward and forward. 

Quite commonly there is no displacement, at least none that is 
appreciable, especially in fractures caused by direct violence ; Fig. 61 
represents a very oblique fracture which has however united with a 
hardly perceptible deformity. The diagnosis is in such cases not 
without some obscurity; the local pain, the swelling, and the im- 
paired motion of the corresponding fingers would accompany a mere 
contusion, if it were severe ; and sometimes even these phenomena 
are at first very slight in degree; my patient, the cooper before 
mentioned, kept at work for nearly a quarter of an hour after his 
accident, and another of my patients apprehended no serious lesion 
until the next day, when he resumed his occupation. These facts, 
as well as the so frequent non-detection of the fracture, are amply 
explained by the position of the bone, sustained as it is by the neigh- 
boring bones as by splints. There are but two symptoms by which 
to recognise it; crepitation and mobility. We may elicit crepitation 
by forcibly flexing and extending the finger, while we fix the upper 
part of the bone with the fingers of our other hand ; or perhaps by 
making torsion of the finger from side to side. As to the mobility, 
the best way of detecting it consists in strongly flexing the finger, 

* For a similar fracture by counter-stroke of the fourth metacarpal near its 
upper end, see the Gazette des Hopttaux, 1833, p. 75. 



A TREATISE OX FRACTURES. 503 

while with the thumb pressure is made into the palm of the hand, 
opposite the supposed seat of fracture, so as to get an angle salient 
posteriorly ; but this attempt must be made with care, lest we give 
rise to a considerable displacement, and then have trouble in cor- 
recting it. 

The displacements are of various kinds. Albucasis, who was the 
first to treat at any length of these fractures, admits two very differ- 
ent varieties of them; one in which the fragments are driven in to- 
ward the palm, while in the other they form an angle on the dorsal 
surface of the hand. I have never seen displacement of the former 
kind; but we may conceive of its occurring, as for instance in the 
patient whose injury was due to pressure by his antagonist's fingers 
against the back of the metacarpus. It would seem to have been 
observed also by M. Lisfranc, in a man with an old fracture of the 
second metacarpal bone, who is said by him to have had a very con- 
siderable deformity in the palm, owing to consolidation of the frag- 
ments in an improper position.* 

But angular displacement backward is much more common, and 
occurs in the majority of fractures resulting from indirect violence. 
It is important to have a correct idea of the nature of this displace- 
ment, which is not so simple as might be supposed. In the first 
place, although the angle would seem to be formed by the projection 
of both fragments, and especially when we try to press the head of 
the bone backward, we need only to examine carefully the parts 
when at rest, to discover that the upper fragment takes no part in 
it ; that this portion of the bone is kept nearly in its normal position 
by its ligamentous attachments to the carpus, and that, if displaced 
at all, it would rather incline somewhat toward the palm. It is the 
lower fragment which rides up backward over the other, while its 
phalangeal extremity is drawn strongly forward ; whence there is a 
more or less marked projection on the back of the hand, due to this 
fragment alone, as it is tilted up over the other ; whence also there 
is a depression of the head of the bone, which is no longer on the 
same level posteriorly with those of the adjoining bones; whence, 
lastly, and what is the most serious of all these complications, a 
notable shortening of the bone, due at once to actual overlapping 
and to angular displacement. All this is remarkably well seen in 
Fi'j. 00, which represents, as has been said, the second metacarpal; 
but besides the displacements there shown, there is another which 
could not be sufficiently brought out in any drawing ; the head of 
the bone had been drawn in toward that of the third metacarpal, and 
at the same time forward, so that the angle between the two frag- 
ments was chiefly salient backward, but somewhat outward also. 

Fractures of the metacarpus, when uncomplicated, unite in twenty- 
five or thirty days. 

* Gazette Medicate, 1832, p. 29. 



504 A TREATISE ON FRACTURES. 

The treatment is very simple when there is no displacement. Hip- 
pocrates applied nothing but compresses and a bandage; and in fact 
the neighboring bones serve the purpose of splints. But it is other- 
wise when there is any prominence or overlapping. 

Albucasis varied the position maintained, and the apparatus, ac- 
cording to the direction of the prominence. Thus when the frag- 
ments were driven toward the palm, he put into the hand a linen pad 
over which the fingers were flexed, surrounding the whole with a 
bandage, and putting a splint of soft leather on the palmar side. 
When on the contrary the prominence was at the back of the hand, 
he kept the hand and fingers extended, and applied both a dorsal 
and a palmar splint. 

Guillaume de Salicet adopted extension in all cases ; A. Pare', 
however, allowed only the flexed position ; and modern surgeons 
have been divided in opinion as to which was right. In our own 
day, Sir A. Cooper and Lonsdale advocate merely keeping the fingers 
flexed over a large pad filling the palm, and confining them with a 
bandage, without any splint. But on the other hand, extension 
seems to count more numerous partisans. B. Bell recommends a 
palmar splint reaching from the elbow to the ends of the fingers; 
Delpech was content to place the hand alone upon a board, to which 
Chelius added a dorsal splint made of pasteboard. Boyer advises 
the application, over the fractured bone, of two small splints of the 
length of the hand, and that the roller, after covering the hand, 
should be carried down over three fingers merely, the one corre- 
sponding to the fracture and the two adjoining ones, which latter 
are to act as lateral splints. 

All these forms of apparatus, it must be confessed, are very 
meagre in their conception. It is of no more use to confine the 
forearm, as Bell did, than to fasten up the fingers as Boyer did. 
Sir A. Cooper's pad, modelled upon that of Hippocrates, only suits 
when there is no displacement; indeed, since the time of Albucasis, 
the necessity of trying to overcome this latter seems to have been 
lost sight of. I know of but two recent contrivances which are 
exempt from this defect, viz., that of M. Lisfranc and that of 
M. Sabatier. 

M. Lisfranc starts with the idea that from the inequality of the 
transverse and antero-posterior diameters of the hand, a roller exerts 
much more pressure in the former than in the latter direction. In 
order to distribute the pressure more equably, he at first contrived a 
sort of vice, whose branches were to be applied one on the back and 
the other in the palm of the hand, and then approximated by means 
of a screw. Afterwards, abandoning this as too complicated, he 
merely placed over each of the interosseous spaces corresponding to 
the injured bone graduated compresses and splints, both in front 
and behind ; thus increasing the thickness of the hand so as to make 



A TREATISE ON FRACTURES. 505 

the bandage press more upon the dorsum and palm than upon the 
edges.* 

It is undoubtedly useful to avoid too great lateral pressure, when 
it is the second or fifth bone of the row which is involved ; but there 
is no such indication with regard to the intermediate bones, which 
are completely protected by their position, and for which in all cases ► 
a simple pasteboard or wooden splint of the width of the hand will 
suffice. The apparatus seems to fulfil another indication, namely, 
the more certain compression of the prominence of the fragments 
backward or forward; but since this pressure is the same both ways, 
its effect really amounts to nothing. And besides, it is not enough 
to press on the angle of the two fragments, to make it disappear, 
but the head of the bone must be sustained and carried back, or else 
it will be merely pushed upon, without the angle being effaced. 

To carry out this idea, I at first placed over the palmar face of 
the head of the bone a thick compress supported by a longitudinal 
splint, in order as much as possible to push up this head above the 
level of the others; while by means of thick compresses and an- 
other splint I exerted strong pressure upon the angle. In this way 
I succeeded in somewhat diminishing the prominence, but not in en- 
tirely effacing it, although the pressure of the dorsal splint was in 
one case so great as to cause excoriation. I therefore modified my 
apparatus, making pressure on the compresses by means of two wide 
transverse splints, one dorsal and the other palmar, strongly ap- 
proximated with strips of diachylon or lead-plaster ; and with this I 
obtained the most satisfactory results. f 

But we must avoid any mistake; the obliteration of the angle 
only partially remedies the deformity, since the overlapping still 
remains. M. Sabatier is so far the only surgeon who has sought to 
overcome this by making permanent extension. 

His patient had a fracture of the third metacarpal bone, with 
shortening of the middle finger by at least half an inch. Extension 
being duly made, the surgeon fastened the middle to the ring-finger 
with strips of diachylon, so as to keep it stretched and prevent its 
yielding to the contraction of the muscles. A padded splint was 
placed on the palmar face of the hand; graduated compresses were 
applied over the dorsal interosseous spaces, and the whole was con- 
fined by a roller embracing also the index-finger. 

Although charpie had been put between the fingers thus fastened 
together, to prevent too great pressure, the pain occasioned by this 
apparatus was so severe that it had to be removed on the third day. 
Fresh charpie was placed between the fingers, and the patient this 
time went comfortably until the thirtieth day. The callus was then 

* Gazette Midicale, lor. rjt. • and Clinique Chir. de la Pitit, tome i, p. 111. 
f Lamaestre. MSm. wa/t Its fr act. des os me'tacarpiens ; Journal de Chirur- 
gie, Oct., 1846. 



506 A TREATISE ON FRACTURES. 

formed, but the finger was shortened by three lines; and the articu- 
lations of the fingers thus stretched were a good deal stiffened, 
making douches, etc., necessary. The middle finger recovered its 
functions very well; but the ring-finger, at the time when the case 
was published, was still liable to occasional slight pains. 

I must confess that this result seems to me too partial and too 
dearly bought to induce me to imitate M. Sabatier's course, and that 
I regard it as an important point in treating this fracture to leave 
the fingers flexed and their joints free. A slight shortening of a 
finger makes no sensible difference in its use; but we see how im- 
portant it is that the surgeon should be aware of all the difficulties 
in the treatment, so as to give a confident prognosis. 

Sir A. Cooper has said something of a fracture of the head of a 
metacarpal bone, in which the head is displaced toward the palm, 
and which might be mistaken for luxation of the first phalanx down- 
ward. I know that such a fracture of the metacarpal of the thumb 
has been considered as a luxation by a careless interne; but the true 
nature of the injury was soon detected. This fracture in my opinion 
would be more correctly called fracture of the neck of the bone, and 
in young subjects it is probably a separation of the epiphysis. I 
have seen one case of it in a woman of twenty-two, who stated that 
she had sustained it when five years old. The lesion had not been 
understood; no union had taken place; the head of the bone seemed 
deformed and movable, and presented a concave lateral surface. 
When the patient flexed her fingers, the head of the bone sank in 
toward the palm of the hand; the upper fragment projected strongly 
backward, contrary to what is observed in fractures occurring higher 
up; and this prominence was so marked that the extensor tendon 
played not over it, but alongside of it, next to the middle finger. 
In the extended position of the fingers, the prominence grew less, 
without entirely disappearing ; and then the flexor tendon might be 
felt on the palmar surface opposite the head of the bone, thickened, 
expanded, and apparently containing a cartilaginous or bony deposit. 
Otherwise, all the movements seemed to have their usual extent and 
freedom. 

This fracture is always readily distinguished from luxation, in the 
first place by the crepitation, and again by the different level of the 
dorsal prominence. In luxation it is the head of the bone which 
projects, and it is upon the same level as its neighbors; in fracture 
the prominence is higher up, and a very marked depression exists 
between the heads of the two adjoining bones. 

Sir A. Cooper recommends treating this fracture by keeping the 
fingers bent over a pad placed in the palm of the hand; but this is 
altogether insufficient. In a case of the kind I used my new appa- 
ratus, mentioned above, with complete success ; only in place of com- 
presses I had to put in the palm a roller of suitable size, in order to 
bear up the lower fragment. 



A TREATISE ON FRACTURES. 507 



§ III. — Fractures of the Phalanges. 

These fractures are not very rare; there are forty-two among our 
list derived from the Hotel-Dieu. Like the preceding, they are 
especially common among men; of these forty-two cases, five only 
were in women. Lastly, they occur chiefly to adults; a fact which 
is explained by the character of their causes. 

Generally but one finger is concerned; in only five of our forty- 
two were two or more involved. In nineteen mention is made of the 
particular finger affected; of these the thumb, middle finger and 
ring-finger each lay claim to five ; the index and little fingers each to 
two. Finally, of ten cases in which the seat of fracture is still more 
precisely defined, the first phalanges were affected seven times, the 
second once, and the third twice. These figures comprehend all 
varieties, simple or complicated; according to Lonsdale, the former 
are most commonly met with in the first row of phalanges, and oftener 
in the forefinger than in any other. 

The direct causes are beyond comparison the most frequent. In 
general the bone is crushed, the fingers being caught between a re- 
sisting surface and a body falling from a height or brought down 
upon them with violence. I have seen a good many such cases from 
masses of stone falling in the quarries around Bicetre ; they are not 
uncommon in workmen who use hammers, from their accidentally 
striking their fingers. Boyer states that when the workmen at the 
mint had to push each coin under the die with the two first fingers, 
it often happened that the last phalanx was caught and crushed by 
the fall of the beam. 

It may easily be seen why the integuments rarely escape injury; 
but the fracture is sometimes simple. A shoemaker had a large 
stone in his hand, when he received a blow from another stone over 
the second phalanx of the middle finger, which was broken.* In 
this case the bone was caught between two resisting bodies; simple 
fracture more commonly results from a severe blow sustained by the 
finger, without the latter resting against anything. Of this Lons- 
dale gives two instances. A child ten years old was playing with 
his comrades, when one of them threw a stone which struck him on 
the index finger, his hand being extended; the first phalanx was 
fractured, the integuments however remaining intact. So also a 
woman, trying to separate two men who were fighting, received a 
blow with a stick on the index finger, the first phalanx of which was 
broken. Ravaton had before given a still more remarkable case. 
Two soldiers had the ends of their thumbs applied over the touch- 
hole of a cannon, while the cartridge was rammed down; the charge 

* Delamotte, TraiU de Chirurgie, obs 359. 



508 A TREATISE ON FRACTURES. 

•went off prematurely, and a violent explosion occurred at the touch- 
hole, fracturing both phalanges of the thumb of one of the soldiers.* 

Fractures by indirect violence are very rare, by reason of the 
smallness and mobility of the phalanges; and I can quote only two 
such cases. In the first, observed by Delamotte, a man broke the 
second phalanx of his forefinger in giving a blow with his fist;f the 
other is related by Lonsdale, of a boy of seventeen, who in a fall 
caught his thumb between two iron bars, and at the instant felt some- 
thing crack. Looking at his thumb, he perceived a deformity which 
he took to be a dislocation; it was a fracture at the middle of the 
first phalanx. 

These fractures are reeognised mainly by the mobility and crepi- 
tation attending them; there is very little displacement, which is 
due almost entirely to the fracturing cause, and is either very trifling, 
or easy to correct. But it sometimes exists as the result of mus- 
cular contraction. Boyer has remarked that the flexor tendons 
draw the lower fragment toward them. To this there may be added 
actual overlapping, and even slight lateral inclination of the broken 
pieces. I have seen this triple displacement in an embosser, who 
had broken with his hammer the first phalanx of the ring-finger, near 
its metacarpal end. The lower fragment overrode the dorsal face 
of the upper, upon which it made a prominence ; whence its anterior 
extremity inclined toward its palmar face, and the finger was shorter 
than the corresponding one on the other hand by more than one- 
third of an inch. By extension the finger was restored to its normal 
length ; but the overlapping recurred immediately ; the contusion and 
laceration of the integuments forbade any strong pressure being 
made upon the phalanx. The only result of the treatment was to 
correct the too great inclination forward of the lower fragment ; but 
the finger was slightly bent toward the middle line of the hand. 

These displacements are seen to be similar to those met with in 
fractures of the metacarpus ; it may be added that the treatment 
presents the same difficulties. 

When there is no displacement, we have only to keep the finger at 
rest for the space of three or four weeks. Celsus advises that it 
should be fixed to a small splint, ad unwn surculum; Paulus Mgi- 
neta began by applying a roller, after which, if the thumb were con- 
cerned, he confined it to the rest of the hand ; if the fore or little 
finger, to the adjoining one ; if the middle or ring-finger, to those on 
each side of it, or sometimes he confined all the fingers together, in 
order better to secure their immobility, and to make them act as 
mutual splints. 

Ambrose Pare' approves of this course ; but he expressly recom- 

* Ravaton, Le Chirurgien oVarmie, p. 319. 
f Delamotte, op. cit., obs. 358. 



A TREATISE OX FRACTURES. 509 

mends keeping the fingers "en figure moijenne, a savoir nestant da 
tout ployes ny dresses ; pourceque s'ils demeuroient autrement, le 
callus qui se feroit depraveroit Taction de la main qui est de prendre, 
ou lien Taboliroit du tout."* This view was adopted in France 
down to the nineteenth century; only some surgeons supported the 
fracture with one or two small pasteboard splints. But in Germany 
and England, extension received the preference ; thus B. Bell fixed 
the broken finger by means of pieces of pasteboard, softened in wa- 
ter and exactly fitted to the shape of the part, doubtless in the form 
of a trough : after which he secured all the fingers, extended upon a 
sort of hand-splint of pasteboard or of thin wood. In the thumb 
only, on account of its isolation and peculiar shape, he advised put- 
ting the wooden splint on the dorsal face, making it reach from the 
base of the metacarpal bone to the end of the last phalanx ; to this 
he added a splint of pasteboard softened in boiling water, so as to 
take the shape of the palmar surface and ball of the thumb ; and 
finally, a triangular pad was put into the angle formed between the 
thumb and forefinger, to serve likewise as a support on this side. 

In France, Boyer advocated extension, which he made by means 
of two splints, one dorsal and the other palmar, at the same time 
fastening the finger also to its neighbors. M. Yelpeau applies also 
the dextrinated bandage in the extended position. 

It will be well first of all to note an inconvenience pointed out by 
Lonsdale, and belonging to all contrivances for permanent extension. 
If, for example, we have to deal with a fracture of the first phalanx, 
and apply a splint passing up into the palm of the hand, the head of 
the metacarpal bone will project against this splint more than that of 
the phalanx will, whence there will be left between the latter and the 
splint a slight space, more marked in the case of the fore and middle 
fingers than in the other two. I admit that this interspace amounts 
to almost nothing in hands with supple joints, and the fingers of 
which can be perfectly extended without difficulty; but in workmen, 
whose callous skin permits only partial extension, it is apt to be very 
considerable. Unless, then, we are very careful, the bandage sur- 
rounding the broken phalanx will force in the two fragments toward 
the splint, making them present an angle forward ; Lonsdale has 
figured a deformity of this kind, observed in a man who two years 
before had sustained a fracture of the index-finger by the fall of a 
heavy spar ; and to guard against such a result, he recommends 
placing between the finger and the splint a pad just filling up the 
interspace. 

But extension itself gives rise to one serious inconvenience, name- 
ly, a stiffening of the joints, sometimes even more troublesome than 

* ["In a medium position, that is. not entirely bent up. nor quite straight; 
lest if they be kept otherwise, the callus formed should impair or entirely abolish 
the grasping power of the hand."] 



510 A TREATISE ON FRACTURES. 

the fracture. Hence B. Bell advises the removal of the apparatus 
on the tenth or twelfth day, in order to make passive motion, which 
should thenceforward be repeated daily. This would, however, be in 
fact an excess of caution ; it suffices to move the joints three or four 
times in the course of the consolidation. But we should do well at 
least in avoiding one of the chief causes of the stiffening, — the ex- 
tension, — and to return to Ambrose Park's plan of semiflexion. 

For my own part, I arrange on the palmar face of the finger a 
small oblong compress, then a splint of firm pasteboard reaching up 
merely to the hollow of the hand, with a slight bend so as to fit the 
finger in the middle position ; one or two strips of lead-plaster, fast- 
ening the finger to the splint, complete the apparatus. We may 
also, if we think proper, fasten the injured finger to its sound neigh- 
bors ; but it must be borne in mind that the spaces between the fin- 
gers increase as we go farther from the metacarpus, and hence that 
by approximating too much the last phalanges, we run the risk of 
causing lateral displacement at the seat of fracture ; which actually 
took place in the patient just alluded to. 

When there is overlapping, if the integuments are uninjured, we 
have merely to reduce the fragments and press them against one an- 
other, to correct it. M. Baudens, in a case of comminution, tried a 
different plan ; he placed the hand on a board-splint, with bands fixed 
by one end to the ends of the fingers and by the other to the board, 
so as to make, in fact, permanent extension. This traction did not 
prevent some shortening of the fingers.* 

The complication of a simple wound is in these cases but trifling; 
Hippocrates remarks that the fracture may be reduced without dan- 
ger, even when one fragment projects through the skin, and that the 
cure may be quite readily accomplished. But it is different when 
the soft parts are bruised and the bone crushed, and the question is 
between immediate amputation and an attempt to save the part. 
Boyer advises amputation when the last phalanx is the one concerned, 
temporising if it is one of the others. I have tried to preserve a 
good many such fingers, but in most cases without success. Still, as 
we sometimes obtain good results, we must not be too hasty; for al- 
though, when from the amount of destruction a cure seems impossi- 
ble, immediate amputation saves the patient time as well as unneces- 
sary pain, yet, small ground for hope as there may be, we should 
remember with Boyer that it is always time enough to amputate 
when the necessity for doing so is clearly demonstrated. 

* Gazette des Hopitaux, 1846, p. 193. 



CHAPTER XV. 

FRACTURES OF THE PELVIS. 

These are generally treated of after those of the thorax or of the 
spinal column, so as to complete the subject of fractures of the trunk. 
But just as I preferred placing fractures of the sternum next to those 
of the clavicle, I have thought proper to connect those of the pelvis 
with those of the thigh, because besides their proximity anatomically, 
several of them present remarkable analogies to one another, either 
in their symptoms or in their indications. 

Fractures of the pelvis are very rare, since in eleven years there 
occurred but ten at the Hotel-Dieu. Although generally the result 
of direct violence, such as falls on the pelvis or excessive pressure, 
we shall have to notice that some of them are caused by falls on the 
feet. They are quite frequently complicated with contusion or lace- 
ration of the pelvic viscera, by which the patient's life is endangered 
much more than by the mere injury of the bone ; sometimes, how- 
ever, this latter may cause death, by the formation of an abscess 
around it. 

These cases present numerous varieties, which however are almost 
always mixed up together in describing them. In order to give more 
precision and clearness to our study, I shall describe first the frac- 
tures proper to each division of the pelvic bones, the sacrum, coccyx, 
ilium or crista ilii, pubis and ischium ; then such as, affecting the 
entire pelvis, present special phenomena of importance, and which I 
shall call double vertical fractures of the pelvis; and finally, I shall 
say a few words concerning fractures in the cotyloid cavity. 

I might have added another section, on comminuted fractures of 
the pelvis, in which it is separated into three, four, six, eight, or 
more pieces ; but besides that they consist merely in combinations 
of the fractures already enumerated, their treatment should be very 
much the same, supposing that we can recognise them and institute 
a treatment. Multiple fractures of the pelvis are apt not to be 
wholly recognised, both from the absence of displacement and often 
also from the obscurity of the crepitation; Dr. Lyon, of Glasgow, 
has even published a case in which seven or eight fractures were dis- 

(511) 



512 A TREATISE ON FRACTURES. 

covered by dissection, although no crepitation had been perceptible 
during life, from any movement whatever of the pelvis.* 

[I have seen a case in which a fracture of the horizontal ramus of 
the pubis on each side, of the ascending ramus of the ischium on 
each side, and of the sacrum vertically with much comminution at 
its lower extremity, with partial separation of the right sacro-iliac 
symphysis, entirely escaped detection during life. The left leg was 
also fractured, and the urethra was ruptured across; the patient's 
death was brought on in a day or two from the last-named injury.] 

The majority of such cases are untreated also, the internal injury 
causing death sooner or later. 



§ I. — Fractures of the Sacrum. 

This fracture is extremely rare; it occurred only once among the 
2358 patients at the Hotel-Dieu. It would seem, however, that it 
was known to the ancients; and Paulus iEgineta gives rules for its 
treatment, whether simple or compound. After this we find no new 
mention of it until the sixteenth century. Ambrose Pard says that 
he has several times seen the sacrum fractured by balls or other crush- 
ing forces, and the patients recover; but if the spine be involved, 
says he, death is almost inevitable. This distinction in the prognosis 
has no foundation either in theory or in practice. 

The sacrum presents in its fractures two varieties ; one which is 
limited to that bone, the other which extends to the other pelvic 
bones. 

Simple fracture always results from a fall on the lower part of the 
sacrum ; but the bone sometimes strikes full upon the ground or upon 
some resisting body, and sometimes by one side merely; hence arise 
quite notable differences in the symptoms. 

I have been able to collect but three observations of fractures 
caused by the former mechanism ;f in all the sacrum was divided 
transversely; and so also it had been in the two long-standing cases 
figured by Sandifort. The seat of the fracture varies considerably. 
In one case reported by M. Judes, the upper portion of the bone is 
said to have been affected. I doubt, however, whether fracture is 
met with above the lower border of the sacro-iliac junction, and gene- 
rally it involves only the lower half of the bone. In one of Sandi- 
fort's drawings, the callus presents an ossified edge a little below the 
third sacral foramen; the other drawing represents a bone with six 
pieces, and the fracture at about the fourth foramen. M. J. Cloquet 

* Archiv. Gtn. de Mfdecine, 1845, tome vii, p. 237. 

f Malgaigne, MCmoire sur les fract. du sacrum et du coccyx; Journal de 
Chirurgie, June, 1846. 



A TREATISE OX FRACTURES. 513 

has seen it at the lower third, and M. Bermond quite low down, near 
the articulation with the coccyx. 

There is one sort of displacement which is almost constant, in which 
the lower fragment, retained in contact with the other by its base, 
has its apex inclined forward. In Sandifort's two specimens, the 
displacement was such that the two fragments seemed fused to each 
other at a right angle; in a preparation bearing the name of Riche- 
rand, in the Muse'e Dupuytren (No. 12,) the apex of the lower frag- 
ment is in the same manner carried forward with the coccyx, and the 
great sacro-sciatic ligaments are drawn in the same direction, so as 
to form a curve convex anteriorly. I know of but two cases result- 
ing from a lateral blow; Fleury de Clermont published one, and I 
observed the other myself, quite recently. In Fleury's patient the 
fracture was transverse, and seated between the second pair of an- 
terior sacral foramina; there was no inclination forward of the coc- 
cygeal fragment, but the apex of the bone was displaced laterally, 
evidently as the result of the direction of the external violence. In 
my own patient, two incomplete and nearly transverse fractures 
divided the sacrum opposite the third and fourth pair of foramina, 
and allowed of the bending of the lower fragment somewhat forward; 
but the principal fracture, running obliquely downward and inward, 
began at the edge on the right side on a level with the third sacral 
foramen, and passed down parallel with the edge as far as the coc- 
cyx ; thus detaching a longitudinal fragment one-quarter to one-third 
of an inch wide, which was drawn over toward the right. There 
was also an oblique fracture of the coccyx. 

The first symptoms of this fracture are the pain and contusion, 
which are always quite severe. In Fleury's case the pain was referred 
rather to the buttock, where the shock had been received, than to 
the actual point of injury ; it was increased by standing up, and still 
more by flexing the body forward. In my patient the pain was com- 
plained of both at the part struck and at the fracture ; it was increased 
by pressure, and extremely aggravated by any attempt at coughing. 

Sometimes these are the only signs of the fracture; but most com- 
monly, in exploring the sacral region, we are struck by the angle 
formed by the two fragments, which is more or less salient poste- 
riorly. By bearing upon the apex of the sacrum the prominence of 
this angle is increased, as is also the pain. The finger passed into 
the rectum finds the point of the coccyx projecting forward more 
than usual, but easily pushed back ; by which movement the pain 
at the seat of fracture is increased, but the angle formed there is 
diminished or even obliterated. Carrying the finger higher up, we 
come to a transverse depression, or rather to an entering angle cor- 
responding to the salient one posteriorly. At the same time we as- 
certain whether or not there is any lateral inclination of the coccyx. 

33 



514 A TREATISE ON FRACTURES. 

Lastly, the different movements communicated to the lower fragment 
give rise at times to more or less distinct crepitations. 

But the coccyx may be carried forward so far as to obstruct the 
anus; which was so markedly the case in M. Bermond's patient, that 
he could not pass his finger into her rectum without first inserting a 
female catheter. The pain was excessive, but was assuaged by the 
presence of the finger in the rectum, which brought the fragments 
together ; when this was removed, the patient cried out loudly to 
have it replaced for her relief. 

With the signs just pointed out, it would be difficult to misappre- 
hend such an injury. But its excessive rarity becomes a fruitful 
source of error, by directing the attention of the surgeon toward 
other lesions ; thus in Fleury's case the pain was combated by means 
of leeches and poultices, and the fracture remained undiscovered 
until revealed by dissection. M. Judes admits that his diagnosis was 
made accidentally ; he had passed his finger into the rectum to ascer- 
tain the state of the gut, and was very much surprised at perceiving 
bony crepitation. Lastly, after the detection of the fracture we may 
err as to its direction and seat ; the autopsy alone revealed to me the 
longitudinal fracture which existed in my patient. 

Fractures of the sacrum unite very well when they are simple ; but 
the severity of the external violence may give rise to serious com- 
plications. Fleury's patient died on the twenty-fifth day, from the 
development of an abscess in the neighborhood of the fracture. 
Mine succumbed at the end of a month, having among other sequelae 
a gangrenous abscess laying bare the sacrum. 

Reduction is easy, the finger being introduced into the rectum, as 
advised by Paulus iEgineta; the difficulty is to maintain it. M. J. 
Cloquet merely kept his patient lying on his side, a position less 
painful to him than any other. A mere inclination of the coccyx 
somewhat forward or outward is not likely to involve any very grave 
inconvenience ; but when this projection gives rise to painful pressure 
upon the rectum, it becomes necessary to correct it. 

M. Judes first conceived the idea of substituting for the finger 
some permanent contrivance. He placed in the rectum a wooden 
cylinder five inches in length by three in circumference, supporting 
it by graduated compresses and a T bandage. Every three days 
this apparatus was removed, and an enema given. After forty-five 
days the patient was able to leave his bed, and soon resumed his oc- 
cupation without pain or inconvenience. 

M. Bermond sought to gain the same end by different means. He 
at first tried the tampon ; a square of linen, spread with cerate, was 
pushed by its middle into the rectum, and the sac thus formed by it 
was stuffed with charpie ; afterwards its angles were drawn out a little, 
and a second tampon formed of them, to hinder the displacement of 
the first. The patient felt some relief; but during the night her 



A TREATISE ON FRACTURES. 515 

abdomen became distended, and next day it was necessary to unstop 
the rectum to give passage to a copious dejection of gas and of fecal 
matter. There was needed, therefore, a tampon which should allow 
any gaseous matters to escape. This M. Bermond made with a silver 
canula five inches long and eight and a half inches wide, and a bag 
so fitted on it as when stuffed to form the inner and outer tampon ; 
at the outer end of the canula were two rings, from which two bands 
passed to a body-bandage, so that the whole apparatus could be 
drawn backward or forward at will; and lastly, a cork was put in to 
prevent the discharges from being constant. 

The patient was thus dressed on the third day; she was kept in 
bed, sometimes on her face, sometimes on her back ; it is curious that 
in her the lateral decubitus was the most painful. While she was 
lying on her back, care was taken to arrange cushions under her 
thighs, so as to prevent any pressure of the sacrum upon the 
mattress. 

This apparatus caused at first a sensation of weight and bearing 
down, which disappeared in a day or two. It was kept in for seven 
days, and then removed; the lower fragment was found still movable, 
although the coccyx kept its place better. The margin of the anus 
was red, swollen, and even slightly excoriated; but M. Bermond 
thought proper to re-introduce the canula, diminishing, however, the 
quantity of charpie around it. 

It was taken out for the second time twelve days afterwards; the 
lower fragment was no longer movable, all the motion which took 
place seeming to be in the sacro-coccygeal articulation. After this 
it appeared unnecessary to re-apply the apparatus ; the slight inflam- 
mation around the anus soon subsided, and in five days after the 
removal of the canula the patient could move about and sit down 
without inconvenience; she soon resumed her customary occupations. 

So much for isolated fractures of the sacrum; those which are 
combined with other fractures of the pelvis result from very various 
causes, and are themselves as varied. Sometimes a man is caught 
between a wheel and a post; more commonly the wheel passes over 
the pelvis and crushes it. In a case of this kind, Lacaze Peroui 
found four fractures of the sacrum, two transverse, and two dividing 
the lower fragment into three pieces. M. Guexe'tin has seen the 
bone broken crucially, that is to say, besides a transverse fracture 
each fragment was in its turn divided by a vertical one. The frac- 
ture may be entirely simple and transverse, as in Richerand's speci- 
men in the Mu.see Dupuytren, before alluded to. All these patients 
succumbed ; it is to be supposed that the gravity of any case depends 
on the number of fractures, and on the amount of visceral injury. 

Lastly, Richerand has published the much more curious case of a 
vertical fracture of the sacrum, discovered at the autopsy on a man 
who had jumped from the second story of a house, lighting on his 



516 A TREATISE Otf FRACTURES. 

left foot. But I shall refer to this case again in connection with 
double vertical fractures of the pelvis. 



§ II. — Fractures of the Coccyx. 

These have only taken a place among fractures through the mis- 
take of a translator of Paulus iEgineta, by which remarks expressly 
referring to the sacrum are made to apply to the coccyx. They are 
extremely rare; I have for my own part seen but one, which was 
joined with a fracture of the sacrum, and was only detected at the 
autopsy ; as to cases in which it exists alone, our positive knowledge 
of them reduces itself to the following passage from M. J. Cloquet. 

" In old persons," says he, " when the different coccygeal bones are 
fused together and with the sacrum, the coccyx may be broken by a 
fall upon the buttocks, or by a kick in that region, as I have myself 
observed to happen in one instance." 

This example is so far the only one with which I am acquainted, 
and it is to be regretted that it is so alluded to without any details. 
M. J. Cloquet indeed mentions a tiler who fell from a roof, and as he 
says fractured one thigh, both legs, and the coccyx ; the coccyx be- 
came carious, and was discharged bit by bit. But he does not ap- 
pear to have himself made out the fracture ; and the caries of the 
coccyx proves no more here than in the observations of J. L. Petit, 
quoted in the same article as proof that these fractures may be fol- 
lowed by serious symptoms. Petit alludes to two cases of caries 
of the coccyx; but I know of no mention which he has anywhere 
made of fractures of this bone.* I shall again refer to this question 
in speaking of luxations of the coccyx. 



§ III. — Fractures of the Crista Ilii. 

Under this head come all those fractures which traverse the iliac 
fossa, or the ilium properly so called, so as to separate from the bone 
a portion or the whole of the iliac crest. Duverney was the first to 
speak of it under the name of transverse fracture of the iliac bones ; 
but when it is very close to the crest of the bone, it has seemed to 
me rather to affect a curved line concave superiorly, starting com- 
monly at a certain triangular enlargement of the crest, overlooked by 
anatomists, and thence running sometimes forward and sometimes 
backward; sometimes even assuming both directions at once, when 
it constitutes a double fracture dividing the crest into two fragments. 

The causes of it are always direct; a fall from a height upon the 

* J. Cloquet, art. Bassin, in the Diet, de Mid. en 30 vols. ; J. L. Petit, (Euvres 
Posthumes, tome ii, p. 205, et seq. 



A TREATISE OX FRACTURES. 517 

side, a heavy blow, powerful pressure, etc. M. Gueretin has seen 
this fracture produced in an unusual way; a man had fallen a dis- 
tance of about twelve feet ; he alighted standing, but as he alighted 
the upper portion of the thigh and the iliac crest rubbed violently 
against a post, and hence there resulted a fracture of the anterior 
half of the crista ilii.* 

The symptoms are at first severe pain, and greater or less con- 
tusion from the external violence. The patient cannot walk at all, 
or if he can it is only with difficulty, from injury of the muscles going 
from the crest to the femur. In one case observed by Duverney, the 
psoas and iliacus were torn across. Sometimes there is no displace- 
ment; this occurs chiefly when the fracture is situated very far from 
the crest; in the case cited by Duverney the ilium was broken trans- 
versely, and the fragments had remained in position. When the 
detached portion is very small, it may likewise keep its place, but it 
is not uncommonly thrown inward. Sanson saw a much more ex- 
tensive displacement; a painter fell from the top of a ladder, and 
broke the crista ilii in its middle third ; the fragment, which measured 
at least four fingers'-breadths each way, was drawn up within the sub- 
stance of the abdominal walls, nearly to the lower boundary of the 
thorax ; it could not be replaced, and the patient recovered with this 
deformity. 

Besides the external contusion, we sometimes meet with lesions of 
the abdominal viscera, of a more or less severe description; but these 
are unconnected with the fracture. Like Sanson, Dupuytren noticed 
that in fractures on the left side the patients are often affected with 
obstinate constipation, which is with difficulty overcome by enemata. 
This phenomenon would indicate that the corresponding portion of 
the colon had been injured; but it is very far from constant. 

The diagnosis is often very obscure, especially when by the em- 
bonpoint of the patient, or by the swelling due to the contusion, the 
parts are masked. In the contrary case, if perhaps we are not at 
once struck by the depression of the fragment, we may grasp with 
our fingers the iliac crest, and by moving it to and fro detect mo- 
bility and crepitation. It is well, in order to relax the iliacus muscle, 
to flex the thigh upon the trunk. Monteggia relates that in an ex- 
amination of this kind, when the thigh was extended the fragment 
was immovable, and the fracture could not be detected, while by 
flexing the limb it was at once revealed by mobility and crepitation. 
LeVf-ille says, moreover, that he has known crepitus to be elicited by 
merely making alternate flexion and extension of the thigh. 

The prognosis is favorable unless from injury of the abdominal 
viscera ; yet this complication is either so rare or so trifling, that the 
majority of these fractures terminate in recovery. Monteggia cites 

* Presse Mtdicale, p. 43. 



518 A TREATISE ON FRACTURES. 

two fortunate cases, Sir A. Cooper two others; the patient mentioned 
by M. GueVdtin was cured in twenty-two days; Lonsdale saw a frac- 
ture of this kind cured by the end of a month, in spite of a large 
slough in the groin; a patient treated by M. Godelier, although 
thrown back by several symptoms due to the violence of his fall, 
walked well on the seventy-fourth day;* and I have myself treated 
two cases which recovered very rapidly and very well. To tell the 
truth, I know of but one instance which terminated fatally; it is 
given by Duverney, in which extensive suppuration, filling the whole 
pelvis, carried the patient off on the fourteenth day. 

The treatment amounts to very little. To reduce the displaced 
fragment, it is recommended to grasp it with the fingers, having 
the thigh strongly flexed, or even putting it at the same time into 
flexion and adduction. Layard devised a more ingenious plan; his 
patient had a transverse fracture, three fingers'-breadths below the 
crest, the fragment being driven inward ; he had the upper part of 
the belly compressed with a towel by two assistants, while another 
assistant pressed the belly at the sound side so as to crowd the vis- 
cera against the detached fragment, and push it into place ; after 
which he maintained the constriction by the towel, and kept the patient 
in bed for three weeks. The cure was complete, and the patient 
walked very well at the end of a month ;f but there is reason to 
doubt whether the apparatus had much to do with the success of 
the case. 

The fragments being reduced as completely as possible, Bottcher 
advises keeping the thigh flexed; Monteggia, arguing from the case 
alluded to, prefers that it should be extended. But most authors 
insist on the application of a body-bandage, not forgetting the use 
of resolvents. 

Resolvents here, as elsewhere, only keep the patient wet and un- 
comfortable, except when the pain and inflammation call for emol- 
lient cataplasms. The bandage is contra-indicated for fractures in 
which there is a tendency to displacement inward. Discussion as to 
the proper position are to say the least useless ; the patient will soon 
find out for himself how he lies most easily. M. Godelier laid his 
patient on the sound side, and he seemed to be comfortable; but 
some days afterwards he turned insensibly on to his back, and felt 
much easier for doing so. 

On the whole, rest in bed, upon the back unless the patient pre- 
fers some other position, is all that is required in these fractures ; 
everything else is useless or hurtful. When there is no notable dis- 
placement, some patients can resume their occupations as soon as 

* Recueil de M6m. de Mid., Chir., et Pharm. Militaires, tome x, p. 266. 

f Philosoph. Transactions, 1744-45, vol. xliii, p. 537. This surgeon has been 
by Monteggia and others called Boyard, the mistake having been copied from 
one to another. 



A treatise on fractures. 519 

the pain subsides, and long before consolidation is complete; one of 
mine walked on the ninth day, and would not stay in the hospital 
after the fifteenth. 

An external wound does not here form a very grave complication, 
provided there is no internal injury. M. Lacheze d'Angers has 
given a remarkable instance of this. A workman, at the bottom of 
a quarry, had had the upper and outer part of the right ilium 
crushed by the fall of a cask; and through the lacerated integu- 
ments the bone was felt comminuted into a number of movable splin- 
ters. A dozen of these were extracted, the necessary incisions being 
made; a threatened peritonitis was warded off by bleediDg; and at 
last, after several months of treatment, the patient was entirely cured 
except a slight halt in his gait.* 



§ IV. — Fractures of the Os Pubis. 

The history of these fractures also is but modern ; Duverney re- 
ported the first observation in regard to them. 

Their causes are commonly either powerful pressure, or the fall of 
some very heavy body upon the anterior portion of the pelvis. I 
have, however, seen a fracture of the pubis the result of the patient's 
jumping from a height of three stories ; and since both he and the 
by-standers affirmed that he alighted first on his feet and then on his 
buttocks, it would seem difficult not to infer that this fracture was 
indirect. 

Sometimes the fracture is limited to the descending ramus of the 
pubis, of which a fragment more or less considerable in size is de- 
tached ; or the body of the bone may be involved, as in the case 
seen by Duverney, in which it was separated into four pieces ; or 
lastly, it may separate the bone from all its connections, of which 
very curious lesion several instances have occurred. In my patient 
above alluded to, who survived his fall only a few hours, I found at 
the autopsy a double oblique fracture, dividing the descending ramus 
near the ischium, and the horizontal ramus close to the ilio-pectineal 
eminence, just grazing by the cotyloid cavity; moreover, the bone 
had been, as it were, torn away from its incrusting cartilage at the 
symphysis, which had therefore undergone an actual separation. 

Fractures of the pubis may be simple or splintered, and with or 
without lesion of the integuments ; but these are in a manner acces- 
sory circumstances. Those which should mainly attract our attention 
are the displacement of the separated portions, and the injury of the 
bladder or urethra. 

II. Nivet exhibited to the Societe Anatomique a double fracture of 

* Archiv. Gin. de Mtdecine, tome xvii, p. 307. 



520 A TREATISE ON FRACTURES. 

the ramus, in which the piece detached had been curiously displaced 
in front of the body of the bone, and had torn the integuments of 
the fold oi the thigh just outside of the labium externum.* 

Maret has related a case of fracture of the body of the bone. The 
fragment seemed carried inward and forward ; in fact, catheterism 
was rendered necessary by retention of the urine, and an obstacle 
was encountered from a hard body which was felt in the right labium 
externum. Maret made an incision an inch and a half long in the 
inner face of the labium, and extracted a very large fragment, which 
involved nearly all the body of the pubis. f 

These cases are the most favorable of all, and perhaps also the 
rarest. There is far more danger when the detached portions are 
driven into the pelvic cavity, tearing the urethra or the bladder, or 
even entering the cavity of the latter. Still, rupture of the bladder 
is not always to be attributed to its penetration by a fragment; in 
M. Nivet's patient it was torn through at its junction with its neck, 
without any apparent communication with the fracture ; this was an 
independent lesion, due entirely to the external violence. 

When the fracture is uncomplicated, it of itself involves no dan- 
ger. Sir A. Cooper says that he saw a successful result in a fracture 
at the junction of the ischium with the pubis, and in others closer to 
the pubic symphysis. The existence of an external wound does not 
add much to the gravity of the case. After the incision made by 
Maret, and the extraction of the bone, the wound took but twenty 
days to heal ; and notwithstanding the formation of an abscess over 
the hip, the cure was completed in six weeks. It should be stated, 
however, that the displacement of the principal fragment, if it com- 
prises nearly the entire pubis, may diminish the circumference of the 
pelvis when consolidation occurs. Lendrick had an opportunity to 
dissect the pelvis of a man who had long before been cured of such 
a fracture ; the distance from the pubic symphysis to the anterior 
inferior iliac spine was lessened by about an inch. J 

But when, besides the division of the bone, there is a rupture of 
the bladder, death is almost inevitable. M. Nivet's patient survived 
but twelve days. In another case, reported by M. Boudet, the ure- 
thra was torn, and a sound which was introduced found its way into 
the rectum ; the patient lived but a short time.§ Sir A. Cooper, 
however, relates a case, although not very fully, in which there was 
diagnosed a rupture of the bladder below the peritoneum ; by the 
use of the catheter, the patient seemed to be doing well. M. Nela- 
ton has communicated to me a much more remarkable case; a woman 

* Bulletins de la Soc. Anatomique, 1837, p. 194. 

1 Maret, Obs. sur les fract. des os du bassin; M6m. de VAcad. de Dijon, 
1774, tome ii, p. 85. 

% Archives G6n. de MMecine, 1839, tome v, p. 484. 
I Bull, de la Socittt Anat, 1839, p. 103. 



A TREATISE ON FRACTURES. 521 

was brought into his wards at Saint-Louis, with her pubis fractured 
by a carriage-wheel passing over it; a fragment had penetrated 
through the bladder into the vagina, and was extracted by the orifice 
of the latter ; yet in spite of extravasation of urine, and an abscess 
resulting from it, M. Nelaton succeeded in accomplishing a cure. 
What follows is however still more curious ; M. Lenoir admitted into 
La Pitie, some years afterwards, a woman suffering from vesical cal- 
culus. She was of the same age with M. Nelaton's patient; she said 
she had been treated at Saint-Louis for a fracture of the pubis ; and 
M. Lenoir having extracted the stone by the urethra, found its nu- 
cleus to consist of a bit of bone. Was this the same patient, or an- 
other? The former seems to me the more probable supposition, con- 
sidering the rarity of cases of this fracture, especially with a favor- 
able termination. 

Still, as shown by Sir A. Cooper, ruptures of the bladder below 
the peritoneum are the only ones susceptible of a cure ; such as com- 
municate with the abdominal cavity are necessarily fatal. 

The treatment of fractures of the pubis amounts to very little. 
We should first endeavor as much as possible to replace the frag- 
ments. When this cannot be done, if there is an external wound, 
we should extract through it all such pieces as might prove injurious; 
but if no such wound exists, we should require very strong reasons 
to induce us to follow the example of Maret. He himself was not 
without apprehension lest in his patient, a girl of eighteen, the loss 
of substance might cause approximation of the hips, some limping 
perhaps, and above all narrowing of the pelvis. He therefore made 
her lie upon her back, with the right thigh flexed and at the same 
time abducted, during the period required for the bone to be repro- 
duced. His attempt was successful ; the pelvis preserved its size, 
the gait remained even and easy, and the girl, being subsequently 
married, was delivered of her children without any trouble. 



§ Y. — Fractures of the Ischium. 

Maret first studied these, in 1765; and I know of but six instances 
which have hitherto occurred. Sometimes the ischium is separated 
almost entirely, in front from the descending ramus of the pubis, and 
posteriorly from the cotyloid cavity, which remains intact; sometimes 
it is only the tuberosity which is detached from the rest of the bone. 

In three cases observed by Maret, Percy, and Rankin, the deter- 
mining cause was a violent fall upon the buttocks, and without doubt 
on the tuber ischii.* In another instance, communicated to Sir A. 

* See Maret, op. cit. ; Histoire de Percy, by Laurent, p. 99 ; Rankin, Gazette 
MMzcale, 1833, p. 53. 



522 A TREATISE ON FRACTURES. 

Cooper by B. Bell, it was the explosion of a mine ; in a fourth, re- 
lated by M. Jobert, the bone was broken by a gunshot wound;* and 
in the last and most curious of all, a woman, who two years before 
had had the inferior pelvic strait narrowed by a double vertical frac- 
ture, had the ischium broken during artificial delivery ;f I shall again 
refer to this in the succeeding section. 

The symptoms vary in different cases, and in the first place accord- 
ing to the height from which the fall may have occurred. The pa- 
tient mentioned by Maret fell from the top of a walnut-tree ; he got 
up with difficulty, but could not walk. Percy's patient was thrown 
from a horse ; he got up and returned home on foot, supported by 
two of his comrades. Rankin's fell a distance of thirty feet ; the 
integuments were torn, the testes laid bare, the urethra divided, and 
the ischium detached from the rest of the pelvis by a double fracture 
with numerous splinters. In Sir A. Cooper's case the fracture was 
likewise attended with a wound, and with splintering. 

If there is a wound, the finger can be applied to the fracture; but 
when the integuments are intact, the diagnosis is the more likely to 
be erroneous from the idea of such a lesion not readily occurring to 
the surgeon's mind. Maret detected no deformity, and no change in 
the length of the corresponding limb ; but in putting the thigh 
through certain motions he perceived crepitation, and by placing his 
hand in the groin and flexing the thigh he noticed a slight mobility, 
accompanied by the same sound. He judged the seat of the fracture 
to be above the tuberosity of the ischium, at that part of the bone 
which goes to form the boundary of the obturator foramen. Percy 
at first overlooked the fracture, and thought the injury was merely 
a severe contusion. But on the subsidence of the inflammation, the 
patient no sooner tried to put his foot to the ground than he felt 
something crack in the thigh, with a sickening pain. Percy then 
laid him on his face, and on examination detected a fracture of the 
tuber ischii. The entire tuberosity was movable under his fingers ; 
and it seemed divided into two portions, as if the incrusting cartilage 
had been torn from the bone. In M. Papavoine's patient, the lesion 
was only discovered by dissection. 

In all the cases, then, the fragments remained in contact, without 
any notable displacement. It would however be presumed that the 
powerful muscles inserted into the tuberosity would draw down the 
detached portion if its fibrous connections were entirely ruptured; 
as was actually the case in M. Jobert' s patient, in whom the frag- 
ments were separated by a space of more than two inches. 

With such a separation, the diagnosis could not present any dif- 
ficulty ; and in ordinary cases it could be pretty clearly made out 

* See Sir A. Cooper's chapter on Intra-capsular fractures of the cervix femo- 
ris ; and Jobert, Plates d'armes a feu, p. 224. 

t Papavoine, Journal des Pr ogres, tome xii, p. 234. 



A TREATISE ON FRACTURES. 523 

from the crepitation, and especially from the mobility. I would not 
however vouch for the accuracy of the opinions given by Maret and 
Percy as to the precise seat of fracture; and I believe it would be 
important, in order to be satisfied of it, to examine the internal face 
of the bone, by introducing the finger into the rectum in the male, 
or into the vagina in the female. 

The prognosis would seem not to be very grave; M. Papavoine's 
patient sank from the effects of her accouchement; the other cases 
recovered, although three of them presented quite serious complica- 
tions. Perhaps any great degree of separation should make us ap- 
prehend some impairment of the motions of the limb. In M. Jobert's 
patient, union being accomplished only through a fibrous band two 
inches in length, the flexion and extension of the thigh were some- 
what hindered, especially during the first two months; but gradu- 
ally, adds the observer, the limb resumed its usual functions, if not 
entirely, at least beyond the expectations of either the patient or the 
surgeon. 

In fractures with displacement, hardly any treatment is called for 
but rest in bed. Maret applied a medicated compress, and a spica 
bandage to the groin. This was done in reference rather to the con- 
tusion than to the fracture; the recovery was rapid and easy. 
Rankin confined himself to extracting the splinters and dressing 
the wounds ; complete consolidation ensued. 

But when there is separation, what is to be done? Percy pro- 
poses a wide leather pad stuffed with hair, and having in the middle 
an opening for the lodgment of the buttocks. One border of this 
pad, rather thin, should extend beneath the loins, the other, very 
thick, beneath the thighs ; and it was hoped in this way to incase 
the tuberosities with sufficient solidity to insure their union. 

I should not myself expect much from this. Such a pad would seem 
to me not only useless but hurtful, since the pressure exerted on the 
fragment or on the muscles attached to it would have the effect of 
carrying it forward. I think therefore that our best plan is to keep 
the patient on his back, his pelvis slightly raised, his legs somewhat 
flexed, and the whole limb immovably confined. 



§ VI. — Double Vertical Fractures of the Pelvis. 

Under this name I shall describe a form of multiple fracture of the 
pelvis, distinguished from all others by a species of regularity, and 
meriting besides special attention in the triple aspect of diagnosis, 
prognosis and treatment. It is a combination of two vertical frac- 
tures, separating at one side of the pelvis a middle fragment com- 
prising the hip-joint; according as this fragment is carried upward 
or inward, the femur follows its movements, and hence result 



524 A TREATISE ON FRACTURES. 

changes in the length and direction of the limb which have often 
misled practitioners. 

Of these two fractures the anterior is almost constantly seated in 
the horizontal and descending rami of the pubis, separating this bone 
from the ilium and ischium ; the posterior is always back of the coty- 
loid cavity, and generally in the ilium; once however it was seen by 
Richerand in the sacrum. Lastly, instead of a fracture, we may 
have here a separation of the sacro-iliac symphysis; of which an 
instance is reported by M. Gerdy.* 

The causes are most frequently direct, such as falling from a 
height upon the hip, crushing of the pelvis between two carriages, a 
wheel passing over the hip, the kick of a horse, etc. These are ex- 
actly such forms of violence as those by which the crista ilii is broken; 
and we sometimes see this fracture combined with the two others. 
It is to be presumed however that to fracture the pelvis from top to 
bottom, the shock should fall lower down and more full, and should 
bear chiefly upon the great trochanter. Hence arises one point of 
resemblance between this fracture and that of the cervix femoris ; 
moreover, what is more remarkable, they may either of them be 
caused by counter-stroke, as in falls on the feet. Richerand's pa- 
tient was a man aged 53, who fell from a second-story window, 
alighting directly upon the left foot. 

In this last case no one could doubt the indirectness of the cause ; 
but even when the shock would seem to fall most directly there is at 
least one of the fractures which must be otherwise produced. In the 
Musee Dupuytren may be seen (No. 11) the os innominatum of a 
young man who fell from a second story; the pubis is completely 
fractured through both its horizontal and its descending ramus; but 
the posterior vertical fracture, which affects the ilium, has involved 
only the outer table of the bone, the inner table having merely yielded. 
It is evident that this last fracture is secondary, the external vio- 
lence first producing the other one and then driving in the iliac frag- 
ment. This view of the mechanism of the double fracture will aid in 
explaining certain displacements which may present themselves in 
connection with it. 

The first phenomena of this fracture are pain, contusion and its 
consequent swelling, and impairment or loss of motion in the lower 
extremity. Generally the foot is more or less everted: in Riche- 
rand's case, however, this deviation did not occur. Sometimes the 
middle fragment is movable, with crepitation; the latter sign has 
also been elicited by pressing from before backward or from behind 
forward upon the great trochanter, by traction upon the thigh, or by 
putting it through different movements. But the most positive in- 
formation is derived from the displacements. 

* Kicherand, Nosographie Chirurgicale, tome iv, Vices du basstn ; Gerdy, 
Archives G6n. de M6decine, 1834, tome vi, p. 378. 



A TREATISE ON FRACTURES. 525 

These displacements are of two kinds. That which is at once the 
most common and the most evident, consists in the carrying up of the 
middle fragment, which draws with it the lower extremity, giving 
rise to an apparent shortening of about half an inch ; Richerand as- 
sured himself in regard to his patient that the anterior superior spine 
of the broken bone was above the level of that of the other by the dis- 
tance mentioned. But in a patient whose pelvis had been caught 
between two carriages, Larrey observed an elongation of the limb of 
as much as an inch and one-third, which persisted even after con- 
solidation was complete.* 

But other displacements quite as serious, and not to be detected 
except by careful examination, consist in the various inclinations of 
the middle fragment. I have mentioned how, in the specimen in the 
Musee Dupuytren, it was driven in by its anterior border, the incom- 
pleteness of the other fracture preventing the posterior edge from 
leaving its place. When both parts of the fracture are complete, it 
may happen that the anterior border of the middle fragment is de- 
pressed into the pelvis, while by a sort of balancing! the posterior 
border projects outward; such a case seems to have been observed 
by Larrey. Lastly the middle fragment has been seen driven in at 
its lower portion, while above it projected outward, the balancing 
taking place in a direction contrary to that in the preceding case; a 
form of displacement tending to widen the superior strait of the 
pelvis and to notably diminish the inferior. All these forms existed 
at once in a woman whose case is related by M. Papavoine, and who 
died long after being cured of her fracture, in consequence of the 
narrowing of the inferior strait.J 

This woman was thirty-four years old, when she received on the 
right side of the pelvis a kick from a horse, producing two vertical 
fractures ; the anterior one was at its usual place, and the posterior 
one was seated in the ilium, a little in front of the sacro-iliac sym- 
physis. She was admitted into the Hopital Saint-Louis, and dis- 
charged in four months with a vicious consolidation. The fragment 
had in the first place risen up a little ; it had also undergone a hori- 
zontal tilting, by which it projected anteriorly into the pelvis, while 
behind it was carried outward so as to overlap the posterior fragment 
by more than an inch, reaching to the upper edge of the sacrum. 
Another vertical tilting had taken place, carrying the crista ilii out- 
ward, and the tuber ischii on the contrary inward, so as to make the 
transverse diameter of the superior strait amount to five inches and 
a half, while the inferior only measured two inches and two-thirds. 
I pass over the other details; these will suffice to explain the sequel 
of this history. 

* Archiv. G&n. >1< .Vcdecine, tome xii, p. 138, and tome xvii, p. 308. 
f [•• Bascule ;" the word means a see-saw, like a scale-beam ; there is no word 
in English which exactly answers to it.] 

% Papavoine, Journal des Progres, tome x, p. 234. 



526 A TREATISE ON FRACTURES. 

The woman came back to the Hopital Saint-Louis two years after- 
wards, pregnant, and near her full term. She had previously had 
five successful accouchements, but this one was terrible ; she was only 
delivered at the fourth day, by means of the forceps, and after such 
violent tractions that, to say nothing of other extremely grave in- 
juries, she had a fracture of the ischium on the right side. Death 
ensued at the end of two days. 

The diagnosis is quite easy when we can readily feel the middle 
fragment moving under our fingers ; otherwise the rarity of the frac- 
ture may put us off the right track ; and hence mistakes in diagnosis 
are not unfrequent. Thus Richerand thought he had to deal with a 
sacro-iliac luxation; in Larrey's case the elongation of the limb gave 
the idea of dislocation forward of the femur. But in ordinary cases 
it is especially fracture of the cervix femoris with which this lesion 
may be confounded; shortening of the limb, eversion of the foot, 
crepitation elicited by pushing up the femur or by pressing upon the 
great trochanter, all these, as well as the nature of the determining 
cause, favor an error into which M. Gerdy admits that he himself 
fell. An excellent safeguard against it is the methodical measure- 
ment of the limb, by which we learn not only that the shortening is 
not in the thigh, but also that the anterior superior iliac spine is 
higher up than it should be. Thus put upon the track, the diagnosis 
.is completely made out by seeking the signs of the anterior fracture 
in the perineum and fold of the groin, and those of the posterior 
back of the trochanter, while the existence of any of the displace- 
ments alluded to may be detected by the finger introduced into the 
vagina or rectum. The prognosis is rendered serious mainly by the 
injury inflicted on the viscera; but even when all danger from this 
source is past, we should not forget that from suppuration, which 
proved fatal in the patients of Richerand and M. Gerdy. Lastly, 
if life is preserved, lameness is very apt to ensue, or narrowing of 
the pelvis, the terrible consequences of which we have just seen. 

The treatment, doubtless on account of the rarity of the lesion, 
has been very little attended to heretofore. Larrey states that in his 
case with elongation he succeeded in replacing the fragments by 
careful manipulation ; but this is rendered uncertain by the fact that 
the limb remained elongated by more than an inch, and that the man 
could only walk with crutches. 

Very little better success has been achieved in overcoming the 
shortening. Richerand says that in his patient it was very easy to 
bring the limb down to its normal length by traction, but that it 
went up again as soon as this was suspended; and as the traction 
gave great pain, it was abandoned, and no apparatus put on. Ames- 
bury treated a fracture of this kind with his mechanical bed ; but 
when the patient, being thought to be cured, was again put on an 
ordinary bed, the shortening was soon seen to reappear; and some 



A TREATISE ON FRACTURES. 527 

months afterwards, having refused to submit to further treatment, he 
had become entirely helpless, with a shortening of several inches. 
Lastly, M. Laugier tried an apparatus for permanent extension, on 
the plan of Desault's, in a young man of twenty, and gave him con- 
siderable relief. At the end of a month the patient was desirous of 
getting up and leaving the hospital; but three weeks afterwards the 
limb had become gradually retracted, although the callus was firm 
enough to sustain his weight in walking.* 

It would seem from all these observations as if reduction would 
always be easy. But this may reasonably be doubted, if we con- 
sider that care has never been taken to measure the limb, any more 
than to ascertain the position of the iliac crest or of the tuber ischii. 
Nor can I see how permanent extension can be efficiently made from 
the ischium as a point d'appui, when the ischium is itself a part of 
the fragment which needs drawing down. 

To sum up, it is necessary first to ascertain the exact relations of 
the fragments ; if there is really shortening, to make extension on 
the leg, and counter-extension from the axillae; but it must be seen 
that the fragment goes properly into its place, for which purpose one 
hand should act on the crista ilii, while the forefinger of the other, 
passed into the vagina or rectum, presses upon the tuber ischii. Of 
course if any other displacement, such as overlapping of the posterior 
by the anterior fragment, is detected, we should attempt to correct 
it by manipulation at the same time. 

Reduction being made as completely as possible, it is to be kept 
up until consolidation is accomplished, that is to say, for at least 
forty-five or fifty days. The tendency to shorten is to be combated 
by means of a double inclined plane, the two thighs being fastened 
together so as to render them less movable, the feet fixed to the foot- 
board, and the body confined by a loop placed beneath the axillae. 
Against the other displacements, I know of nothing more efficacious 
than a very firm body-bandage, or what is better, a wide girdle 
buckled round the pelvis above the trochanters, with compresses to 
push the iliac crests inward if this be necessary; while a broad pad 
between the thighs, and a handkerchief fastening the knees together, 
would have the effect of carrying the two ischiatic tuberosities out- 
ward. It is in these cases particularly that a well-contrived bed is 
desirable, to enable the patient to be raised up and to go to stool 
without deranging the pelvis. 



§ VII. — Fractures in the Cotyloid Cavity. 

Most of these fractures being attended with displacement of the 
head of the femur, I shall postpone their more extended discussion 

* Laugier, Bulletin Chirurgical, tome i, p. 66. 



528 A TREATISE ON FRACTURES. 

to the chapter on luxations of the hip-joint. But since the crepita- 
tion to which they give rise has sometimes led to the idea of fracture 
of the cervix femoris, and moreover as in some rare cases they exist 
without any concomitant dislocation, it has seemed to me to be bet- 
ter that I should say a few words here concerning them. 

These fractures present quite numerous varieties. Courant saw 
one which divided vertically the ilio-pectineal eminence, the cavity, 
and the ischium. Sir A. Cooper has described and represented a 
stelliform fracture separating the three pieces of the os innominatum 
almost exactly at their line of junction, and Sanson met with a pre- 
cisely similar case in a woman of thirty. In each of these cases the 
whole thickness of the bone was involved. Sometimes the injury is 
limited to the cavity itself; it may then be seated at its deepest part, 
as in a young man treated by Sanson, whose fracture was caused by 
leaping from a height, and in whom the bottom of each acetabulum 
was comminuted and driven into the pelvis without displacement of 
either femur ; sometimes it is merely a part of the raised edge which 
is detached from the rest of the bone. 

On the whole, if there is no appreciable displacement, the fracture 
only reveals itself by the crepitation, and would be with difficulty 
distinguished from a fracture of the cervix femoris unattended with 
shortening. The mistake would however be of very little conse- 
quence, the treatment in either case consisting merely in the main- 
tenance of rest during the time required for consolidation. Any 
considerable displacement, throwing the head of the femur out of 
place, would belong properly to the same category with luxations. 



CHAPTER XVI. 

FRACTURES OF THE FEMUR. 

Of all the bones, the femur is the one most frequently broken ; it 
was affected in 808 of the 2328 simple fractures at the Hotel-Dieu. 
But all parts of the bone are not equally so predisposed; thus of 
these 308 cases, 104 were in the cervix, 207 in the shaft, and five 
only, under the title of fractures of the knee, at the lower extremity. 
The small number of these latter forbids our deducing any statistics 
as to their principal predisposing causes ; but fractures of the cervix 
and shaft offer a better field for such researches, and we shall meet 
with marked differences among them. 

Fractures of the shaft are more frequent in men than in women, 
the proportion being 145 to 62. Those of the cervix are, on the 
contrary, somewhat more common in women; of the whole 104 but 
48 were in men. 

The diversity in respect to age is no less marked. Fractures of 
the shaft occur almost indifferently at all periods of life; 130 were 
in persons under forty, only 77 above that age. Fractures of 
the cervix are the almost exclusive portion of old age; under fifty 
years there were only fourteen; above, there were ninety. And 
the antagonism is far more striking if we compare the two forms of 
fracture in early infancy; thus from two to ten years I have known 
of but one fracture at the upper extremity of the bone, against 
twenty-one of its shaft. It may almost be said that at this age, of 
all forms of fracture that of the cervix femoris is the most rare; but 
we may certainly affirm that that of the shaft is the most common. 
There were of the patients at the Hotel-Dieu, in all, sixty-three 
children of this age, and I have just said that of these twenty-one, — 
just one-third, had broken the shaft of the femur; and so also at 
the Hopital des Enfants, of a total of sixty specified fractures oc- 
curring at that age, twenty-two belonged to the shaft of the femur. — 
a proportion very nearly the same. 

The predispositions of each sex vary much, according to age. Of 
the fractures of the shaft, we find : — 



■orn 2 to 20 years, 


35 boys, 


12 girls, = 3 to 1 


" 20 to 40 " 


47 men, 


6 women, = 8 to 1 


" 40 to 60 " 


43 " 


15 « = 3 to 1 


u 60 to 80 " 


20 " 


29 " = 2 to 3 




34 


(529) 



530 



A TREATISE ON FRACTURES. 



And of the fractures at the upper extremity :- 



rom 4 to 50 years, 


9 men, 


5 women, = 2 to 1 


" 50 to 60 " 


9 " 


10 " = 1 to 1 


Over 60 " 


30 « 


41 « = 3 to 4 



[During the five years between January 1, 1853, and January 1, 
1858, there were treated at the Pennsylvania Hospital 196 fractures 
of the femur; and the following table will show the relations of age, 
sex, and seat of fracture: — 



MALES. 
Neck. Upper Th'd. Middle. Lower Th'd. Not Stat'd. 



Below 10 - 
10 to 25 - - 
25 to 60 - - 

Above 60 - ■ 


- - 25 

- 49 

- 81 

- 12 


2 
17 

7 


3 

2 
6 
2 


18 

32 

36 

1 


3 

9 

18 
1 


1 
4 
4 
1 




167 


26 


13 


87 


31 


10 






FEMALES. 










Total. 


Neck. 


Upper Th'd. 


Middle. 


Lower Th'd. 


Not Stat'd 


Below 10 - 
10 to 25 - 
25 to 60 - 

Above 60 - 


- - 3 
■ - 3 

- - 8 

- - 15 


1 

3 

12 





1 

2 
1 
2 


2 

3 

1 


1 



29 



16 



In five of these cases both thigh-bones were broken. 
In two there was fracture of one femur in two places. 
In one the great trochanter was broken off.] 

The influence of the seasons is not very marked ; but while during 
the winter season the fractures of the shaft of the bone are increased 
by one-twelfth, those of the cervix are more numerous by one-fifth. 

Although all fractures of the femur come thus under three general 
heads, this division is quite insufficient for their close examination. 
At the upper extremity four very different varieties present them- 
selves: those of the neck, intra and extra-capsular ; those of the 
great trochanter ; and those just below the two trochanters. Next 
come those of the shaft; and lastly, at the lower extremity, those 
just above the condyles, and those of the condyles which pass into 
th# joint. 



§ I. — Intra- Capsular Fractures of the Cervix Femoris. 

This name is given to fractures dividing the cervix within the 
limits of the synovial membrane, so that if this membrane were di- 



A TREATISE ON FRACTURES. 531 

vided at the same level, the fracture would communicate at once 
with the joint. But as beneath the synovial membrane there is an- 
other layer covering the bone, a dense and solid periosteum, appa- 
rently a reflected portion of the fibrous capsule, it may easily be 
seen how this may either remain intact, or be partly or completely 
torn asunder, making three very different conditions under which 
the same fracture may occur. Stanley saw two cases of intra-cap- 
sular fracture, without any injury of the periosteum or of the syno- 
vial membrane; two other instances have been reported, one by 
Iff. Mayor and the other by Mr. Bransby Cooper.* The cases in 
which complete rupture occurs are almost as rare; it is undoubtedly 
most common to find the periosteum and synovial membrane partially 
torn across. 

It is not only the soft parts that may escape complete separation ; 
in some cases the bone itself is but partially divided. Colles has 
described three fractures of this kind, in which, the bone being 
broken transversely near its head, its cortical layer remained intact 
posteriorly in a good part of its width. In another case, described 
by Wilkinson King, the cortical layer was uninjured above and in 
front, f 

But these are rare exceptions ; in the immense majority of cases 
the fracture is complete, but offers some varieties in regard to its 
seat, its direction, and the arrangement of its surfaces. 

Most commonly the cervix is divided very close to the head of the 
bone, at the point where it is narrowed; quite often, indeed, a small 
portion of the head itself is involved. Sometimes, again, a larger 
piece is separated, the division occurring near the trochanters. Be*- 
clard presented to the Faculte a specimen which he made out to be 
a fracture of the head of the femur into four pieces, perfect consoli- 
dation having occurred. J But the state of the surrounding parts, 
and especially of the cotyloid cavity, affords ground for doubt whether 
we have not here merely a senile deformity; and I know of no well- 
attested instance of fracture limited to the head of the femur. 

A- to the direction of the fracture, it sometimes divides the cervix 
perpendicularly to its axis, constituting a transverse fracture ; some- 
times it is oblique, when its course may vary. The fracture represented 
in Fig. 62 is oblique downward and outward; but which is perhaps 
the most usual direction. R. W. Smith has described fractures 
running downward and backward, downward and forward, etc. ;§ 

* Stanley, Medico-Chir. Transactions, vol. xiii, p. 504, and vol. xviii, part i; 
Mayor, Go:/.. Midicale, 1834, p. 612 ; B. Cooper, L Experience, tome i, p. 505. 

t Colles. Fracture of (he Neck of the Femur, illustrated by Dissections; 
Dublin Hospital Reports, 1818, tome ii, p. 334; W. King, Guy's Hospital Re- 
ports, Oct., 1844, p. 347. 

% Bulletin de la Faculty, 1816, p. 86. 

§ R. W. Smith, Obs. on the Diagnosis and Pathology of Fractures of the 
Neck of the Femur; Dublin Journal of Med. Science, Sept., 1840. 



532 A TREATISE ON FRACTURES. 

lastly, Sir A. Cooper mentions, on the authority of Brodie, an oblique 
fracture in which the upper fragment prevented the other from slip- 
ping up, and which therefore would seem to have passed downward 
and inward. It should be remarked that some of those oblique frac- 
tures extend beyond the limits of the synovial membrane, consti- 
tuting mixed cases; that is, at once intra and extra-capsular. But 
as they do not perceptibly differ from those intra-capsular fractures 
in which part of the periosteum remains intact, I shall not examine 
them separately. 

All these forms of fracture are generally serrated; and often the 
serrations are so large and firm as to keep the two fragments in per- 
fect contact, or at least to limit their displacement. Displacement, 
indeed, cannot then occur unless one or more of these serrations is 
broken, forming so many splinters ; and not unfrequently one of these 
splinters is seen buried in the spongy texture of the head of the bone. 
Sometimes the irregular end of the lower fragment is driven, without 
any splintering, into the substance of the inner piece or head; and 
lastly, there may be a mutual penetration; thus in one specimen at 
the Musee Dupuytren (No. 184,) the inner fragment, conical in shape, 
occupies a cavity in the middle of the end of the outer one; while 
the bevelled edge of this cavity has grasped the circumference of 
the head of the bone, in the same manner as is shown in the head of 
the humerus in Fig. 26. 

Intra-capsular fracture is more common in women than in men, 
and occurs almost exclusively in old people. Sir A. Cooper sought 
to make of this double predisposition a sort of characteristic; and 
in his view the majority of fractures of the cervix femoris in persons 
over fifty years of age are intra-capsular. Recently a quite con- 
trary opinion has been advocated; M. Bonnet, of Lyons, has even 
stated that extra-capsular fractures form the immense majority, and 
are almost the only ones seen ; *' and M. Nelaton, without going so 
far, asserts that they are by far the most frequent. 

Neither of these opinions is sustained by facts. Sir A. Cooper 
bases his opinion on his long practical experience, which is, however, 
an equivocal source of proof, owing to the obscurity of the differential 
diagnosis. M. Bonnet adduces clinical observation, experiments on 
the dead subject, deductions from anatomical structure, and lastly, 
autopsies. The first three of these sources may indeed furnish pre- 
sumptive evidence, but not positive proof; and as to the fourth, it 
suffices to say that M. Bonnet, at the time when his Memoir was pub- 
lished, had seen in all but four dissections of fractures of the cervix, 
which might perhaps have just chanced to be extra-capsular cases. 

In order to solve such a question, we need quite a large number 
of anatomical specimens, collected at random and without any pre- 

* Bonnet, Mim. sur les Fract. du F6mur, etc. ; Gazette Mtdicale, Aug. and 
Sept., 1839. 



A TREATISE ON FRACTURES. 533 

formed opinion. Now, putting together all the fractures of the cer- 
vix femoris preserved in the Muse'e Dupuytren in Paris, in St. Bar- 
tholomew's Hospital in London, in the two museums of the College 
of Surgeons in Dublin, and in the museum of the Richmond Hos- 
pital School, also in Dublin, I have arrived at the following results: 

Musee Dupuvtren, 32 fractures, 20 intra-capsular. 

St. Bartholomew's, 12 " 6 " 

Dublin Museums, 18 " 12 " 

Eichmond Hospital, 41 " 23 " 

103 61 

The proportion is therefore as three to two, or a majority of one- 
third for the intra-capsular form ; I have not taken into the account 
two specimens in the Muse'e Dupuytren and Richmond Hospital Mu- 
seum, in which is presented the very rare combination of one frac- 
ture within and another without the capsule.* Before this array of 
cases, arguments drawn from a few dissections, and even those giving 
contradictory results, fall to the ground. Thus after M. Bonnet of 
Lyons, who found four fractures in succession outside of the capsule, 
comes his pupil, M. Rodet, who in two other autopsies found the 
fracture to be within it. Thus also, M. Mercier, at Bicetre, found 
in eight autopsies three intra-capsular fractures, four extra-capsular, 
and one below the trochanters ;f while I myself, in the same hospital, 
found in eight other autopsies one fracture below the trochanters, five 
within the capsule, and only two outside of it. 

On the whole, intra-capsular fractures, without being so frequent 

* Some details as to the sources of these figures may perhaps be properly 
given here. The Musee Dupuytren contains thirty-five specimens of fracture of 
the neck of the femur ; but two of them (Nos. 177 and 189) seem to me of very 
equivocal character; another, (Xo. 200,) is a gunshot fracture, and throws no 
light on the present question. M. Xelaton has asserted that the number of intra- 
capsular fractures in this museum is due to the fact that the specimens were col- 
lected at the time when Dupuytren was sharing in the discussion raised by Sir 
A. Cooper as to the mode of union of this form of fracture, so that they were 
preserved in preference. This is a mistake. Of the thirty-five specimens, but 
three were deposited by Dupuytren, and nearly two-thirds of the number by the 
SoeteU Anatomique; so that after having made a resume of the fractures pre- 
sented to this society during the last eleven years, I have abstained from bring- 
ing them in for fear of making a double use of them. 

The number of fractures in the museum at St. Bartholomew's was communi- 
cated to Sir A. Cooper by Stanley ; that in the museum of the College of Sur- 
geons in Dublin by Colles. Colles, in the memoir already quoted, reports a series 
of eleven autopsies made by him within three years, among which he found eight 
intra-capsular fractures. I have made use only of the numbers given to Sir A. 
Cooper, likewise for fear of making a double use of others. 

Finally, the numbers from the Richmond Hospital Museum are quoted from 
the before-cited memoir by R. W. Smith. They comprise forty-two cases ; but 
one of these, given as a specimen of a consolidated intra-capsular fracture, might 
be ascribed to an entirely different lesion. 

t Mercier. M&m. #wr qudques parlic. de Vhist. des.fract. de Vextrtm. sup. du 
f&mur; Gaz. M6dicale, 1835, p. 561. 



534 A TREATISE ON FRACTURES. 

as stated by Sir A. Cooper, are more numerous than those of the 
other variety. A graver error is committed by the same author, in 
saying that. they almost always occur in subjects over fifty years of 
age, whereas extra-capsular fractures are chiefly met with in younger 
persons. Morgagni examined by dissection an intra-capsular frac- 
ture in a woman of forty, who had sustained it in her youth;* Stanley 
saw another in a young man of eighteen; and it would be easy 
to spin out such a list of isolated instances. But of the twenty-three 
cases at the Richmond Hospital, three were in subjects not over fifty 
years old, and four others in persons below that age ; while of seven- 
teen cases of extra-capsular fracture in which the age was noted, only 
one was in a patient under fifty. 

[In the United States, the general opinion is in favor of Sir A. 
Cooper's view. In the table on page 530 no separation is instituted 
between intra-capsular and extra-capsular fractures, both being in- 
cluded in the second column; this is because the record kept is defi- 
cient in this respect in reference to some of the cases ; but of the 
seven male and twelve female cases of fracture of the neck of the 
femur in persons over sixty, every one followed the usual course and 
had the usual result of the intra-capsular form. Of the cases occur- 
ring in persons below sixty, nearly every one was produced by a fall 
or a direct blow over the trochanter, and from its course and result 
seemed quite plainly extra-capsular; those which deviated from this 
rule were all in persons verging toward the higher limit of the period.] 

The determining causes are all indirect, except gunshot wounds, of 
which I shall make no mention here. Sir A. Cooper says that the 
most frequent cause in London is a false step, the subject walking 
along the curbstone and suddenly slipping into the street; the dif- 
ference of level being several inches. The cervix femoris gives way, 
and the patient falls, his fall being the result and not the cause of 
the fracture. The lesion in question may however ensue from a fall 
upon the great trochanter. But Sir A. Cooper insists strongly upon 
the fragility induced by senile atrophy in the cervix, making it liable 
to fracture from the slightest causes; citing as an instance the case 
of a woman who was standing at her counter, and turning quickly 
toward a drawer behind her, caught her foot against a projection in the 
floor so that it could not follow the movement of her body; and this 
slight check was sufficient to break the cervix femoris. 

All this is accurately described, but upon the living subject ; and 
the question recurs whether it really applies to intra-capsular frac- 
ture. M. Rodet has lately endeavored to clear up the point by ex- 
periment^ he submitted to various forms of violence plaster models 
of the femur, and subsequently the bones themselves ; and he divides 
all the causes of intra-capsular fracture into three classes, viz. : 

* Morgagni, De sedibus, etc. ; epist. lvi, art. 10. 
f Rodet, Thdse inaug., Paris, January 20, 1844. 



A TREATISE ON FRACTURES. 535 

(1.) Blows directed vertically, including falls on the feet or knees, 
and slipping off the curbstone as observed by Sir A. Cooper; the 
fracture occurs then the more readily, since the thigh is abducted, 
and the force acts on the head of the bone from above downward, 
and from without inward, relatively to the axis of its shaft. M. Rodet 
relates indeed the case of a man, who in falling out of a loft with his 
leg flexed and his thigh abducted, struck the inside of his knee 
against a horizontal beam; at the autopsy an intra-capsular fracture 
was discovered. 

(2.) Blows applied to the trochanter from before backward, or any 
forcible rotation of the femur in this direction; the fracture is then 
at the middle of the cervix, and entirely within the capsule. 

(3.) Blows applied to the trochanter from behind forward, or any 
forcible rotation of the femur in this direction; to this class would 
belong the case of the shop-woman mentioned by Sir A. Cooper. 
M. Rodet relates also the instance of a man who in falling backward 
struck the posterior face of the trochanter against an angular body, 
and had a fracture entirely within the capsule except a very small 
point at its back part, which was outside of it. 

From his observations and experiments, M. Rodet concludes that 
in general fractures of the cervix femor is present a certain relation 
between their seat and direction and the direction of the violence 
giving rise to them; and he thus arranges the three orders of causes 
with their results : 



{Vertically, 
Autero-posteriorly, 
Postero-anteriorly. 



( Oblique, 
Fractures < Transverse, 
J Mixed. 



And finally, blows received transversely, as in falling on the side, 
inevitably produce extra-capsular fractures. 

There is some truth in this theory, and I have seen some cases 
supporting it. An insane patient fell backward in going down a stair- 
way, got up, and fell again, this time striking upon the mass of the 
right buttock ; he died eight months afterwards, and I found an 
intra-capsular fracture. I have had represented (Fig. 65) a fracture 
produced by a like cause in an old man upon whom a trick was 
played, his chair being pulled away as he was sitting down in it. 
But in respect to falls on the side this theory is evidently defi- 
cient. The majority of our patients ascribe their fractures to falls 
of this kind; such was the case with the old man whose femur is 
shown in Fig. 62, as a type of intra-capsular fracture. M. Rodet's 
experiments are faulty chiefly in that they were made on the femur 
isolated from the pelvis, direct blows being inflicted at the base of 
the great trochanter. But in falls on the side, it is very rarely that 
the trochanter is struck in a transverse direction; the neck of the 
femur runs normally outward, downward, and backward, and conse- 



536 A TREATISE ON FRACTURES. 

quently the trochanter is a little back of the head of the bone ; so 
that in a fall directly upon the side, it would strike by its anterior 
edge, and hence be acted on at the same time from without inward, 
and from before backward. This explains why, in the majority of 
cases, the periosteum and synovial membrane are torn anteriorly, 
and the fragments themselves separated anteriorly and driven to- 
gether posteriorly. 

Nor can we explain, with M. Rodet's three classes of causes, those 
very different cases in which the periosteum is torn in front and 
above, in front and below, or even above only ;* and practice shows 
the true rationale, which is outside of his theory. I have seen 
an old man who being in danger of falling sideways, threw his body 
over the other way to catch his equilibrium, and in doing so felt a 
sharp pain in the hip, before he fell down; the fracture therefore 
occurred here from inordinate adduction. At another time, I was 
trying to produce a luxation downward and forward by violently ab- 
ducting the thigh, in a dead subject eighty-one years of age, when 
suddenly there occurred a mixed fracture, that is to say, partly 
within and partly without the capsule. Lastly, the correspondence 
between each variety of fracture and each of the causes pointed out 
is far from being constant or certain; the fracture represented in 
Fig. 65, which judging from its cause should have been a mixed one, 
is plainly intra-capsular. 

On the whole, from an attentive study of known facts, and from 
my own observations, I incline strongly to the opinion that, even in 
falls on the feet and on the hip, most of these fractures occur from 
forced movements of the hip-joint, adduction or abduction, or rota- 
tion either inward or outward. It is from similar causes that most 
luxations of the hip arise ; the difference of result depends solely 
upon the strength of the capsule, which gives way in luxation, but 
resists in fracture. 

Intra-capsular fractures, unattended with displacement, present 
no other symptoms than the local pain, and more or less impairment 
of motion in the limb. When there is displacement, which is most 
commonly the case, the following phenomena have been ascribed 
to them. 

Pain ; swelling of the soft parts ; loss of power in the limb ; short- 
ening ; drawing up and loss of prominence of the great trochanter ; 
eversion of the foot ; and finally crepitation. Each of these calls for 
special study. 

(1.) The pain is located particularly in the fold of the groin, and 
according to Sir A. Cooper, at the level of the insertion of the psoas 
magnus and iliacus internus muscles into the lesser trochanter, or a 
little above this point. I have verified this statement in several 

* See R. W. Smith, op. cit, (in Dublin Journ., Sept. 1840,) obs 5, 13, and 14. 



A TREATISE ON FRACTURES. 537 

cases ; once I even saw the integuments raised up by the tendon of 
those muscles, which seemed as if they were shrunken. But I have 
also seen very severe pain caused by pressure posteriorly, either at 
t^e level of the trochanter or higher up. 

Sir A. Cooper adds that the pain is less here than in extra-cap- 
sular fracture. But this seems to me a mistake, and I incline rather 
to just the contrary opinion. Generally the pain is but moderate in 
either case, and is easily assuaged by a proper position and by rest; 
but it is not uncommon to witness the most acute pain in intra-cap- 
sular fractures. Boyer relates an instance in which, from the outset, 
the patient complained of severe pain at the inner side of the thigh, 
and even around the knee ; moderate extension, attempted at inter- 
vals, so increased this suffering, that it had to be given up. Swan 
saw a case in which the pain was so intense that opium had to be 
administered, and even this gave but little relief.* In one of my 
patients the pain was so severe and persistent that I was at first led, 
adopting the idea of Sir A. Cooper, to think the fracture an extra- 
capsular one. The subject of Fig. 62 was troubled for the first few 
days with cramps throughout the limb, and with terrible pains, which 
were increased by the slightest motion, and especially by coughing. 
On the sixteenth day these pains subsided; but at the end of two 
months, when I tried to make him get up, they recurred frightfully, 
affecting the hip and knee at the same time, and increasing upon the 
least motion ; and they lasted thus for about six weeks. I then tried 
again to get him out of bed, but in vain ; every movement was pain- 
ful, and he was, like Boyer's patient, bed-ridden for the remainder 
of his life. 

To what cause are such pains to be attributed? Not to the dis- 
placement, for in Swan's case there was no displacement, and the 
fracture was found in great measure united. I think they are due 
to inflammation, set up in the hip-joint and radiating by sympathy to 
the knee. In the second of my two patients, who died in five 
months and a half after the accident, the round ligament was mixed 
up in one reddish mass with the fatty pad at the bottom of the coty- 
loid cavity ; and union had been commenced, by means of reddish false 
membranes, between the head of the femur, the cotyloid cavity, and 
the capsule. In the other, who survived the injury more than eight 
months, besides a similar agglutination of the round ligament, the 
head and neck of the femur had contracted very firm adhesions 
above and in front with the capsule, and at the points occupied by 
these adhesions the synovial membrane and the articular cartilage 
had disappeared. 

(2.) The swelling is generally very slight ; in one case, however, 

* Sir A. Cooper, Lettre sur les fr. du col du fimur; Gaz. Medicate, 1834, 
p. 503. 



538 A TREATISE ON FRACTURES. 

I saw it extend from the hip down to the knee. I do not know at 
present of any instance in which it has been attended with any 
ecchymosis externally; but it should be mentioned that in Boyer's 
case, just quoted, the autopsy revealed an effusion of blood into the 
substance of the quadriceps femoris muscle; and that Swan also 
found by dissection some ecchymosis among the muscles around the 
fracture, as well as in the cellular tissue around the sciatic and an- 
terior crural nerves. 

(3.) The loss of power in the limb generally includes all the volun- 
tary movements. Thus the patient cannot rise, nor stand upon the 
injured limb ; when he is lying down, he cannot adduct or abduct it, 
or rotate it either outward or inward. Boyer has strongly insisted 
on one phenomenon in connection with the loss of power; the patient, 
says he, cannot raise the limb as a whole, and his endeavors to do 
so have no effect except to produce a slow and limited flexion of the 
leg and of the thigh, and to approximate the foot to the buttock, 
without raising it off the bed. 

There are in this respect notable exceptions. Thus the subject of 
Fig. 62 raised his foot with ease off the bed, although I had clearly 
made out a shortening of an inch. The subject of Fig. 65 got up 
after his fall, regained his chamber, and walked again the next day ; 
and most observers have cited analogous facts. 

How are these anomalies to be explained? Desault alleged the 
interlocking of the fragments ; to which Boyer adds the resistance 
of the uninjured periosteum. These are doubtless favorable circum- 
stances, but they do not sufficiently account for the phenomenon; 
thus in one of Stanley's patients the contact of the fragments was 
as exact as possible, and yet the limb had lost all power of motion. 
On the other hand I had assured myself of shortening, and hence 
of the disjunction of the fragments, in the old man who could raise 
his whole limb ; and although the displacement had not been noted 
at the outset in the other patient who walked just after his fall, yet 
the autopsy subsequently showed very great shortening. Sometimes 
again, on the subsidence of the pain and irritation, patients with 
shortening can stand very well on the injured limbs ; why could they 
not do so at first? What hindered them was just the pain; and 
here, as in fractures of the clavicle, the severer the pain the more 
difficult is any movement which will aggravate it ; with less pain or 
with more fortitude, some patients can attempt motions and efforts 
which to others would be impossible. Only, what it seems to me im- 
portant to notice, these movements are now accomplished not by the 
hip-joint, but in great part at least by the lumbar portion of the 
spinal column. 

(4.) The shortening of the limb seems to strike the eye first from 
the relative position of the heel, of the malleoli and of the knee, to 
those of the sound side, the former being on a higher level. But 



A TREATISE ON FRACTURES. 539 

the surgeon should bear in mind the small value of all these signs. 
The drawing up of the heel, of the malleoli, of the knee, by no 
means indicate that the limb is shortened, but only that the pelvis is 
tilted up. To show how uncertain a dependence is to be placed upon 
them, we need merely cite an instance from M. Mayor, in which were 
observed at ten paces the well marked characters of fracture of the 
cervix femoris, while the autopsy revealed only a scarcely perceptible 
fissure. We must therefore seek to estimate the shortening with 
accuracy, and for this purpose should resort to methodical measure- 
ment, according to the rules laid down in the article on Diagnosis. 

This being understood, it is important to know what may be the 
extent of the actual shortening, and first under what circumstances 
it takes place. 

The head of the femur, the shaft being held vertically, is some- 
times as much as two-thirds of an inch above the summit of the great 
trochanter ; this is represented by the dotted lines in Figs. 62 and 
63 in a femur belonging to a subject seventy-six years old. Some- 
times again it is much lower; in an old man of eighty-seven, {Fig. 
68,) its elevation reaches scarcely one-third of an inch. "When the 
cervix is fractured and the limb shortened, it is because the head 
descends below its natural level; but taking the summit of the tro- 
chanter as the point for comparison, it is easily seen that the short- 
ening may vary by at least one-third of an inch, while the head is 
in just the same relative position to the trochanter. 

This lowering of the head takes place in two ways. Sometimes 
the outer or lower fragment rises, not leaving the upper one, but car- 
rying it up also ; so that the surfaces of the fracture are separated 
above, and the head of the femur, unable to ascend, remains inclined 
downward, below its normal level. The shortening cannot in such 
a case amount to much; I have in my possession a specimen of the 
kind, in which, the head being brought down on a level with the top 
of the trochanter, the actual shortening is not more than from one 
to two-thirds of an inch. Sometimes again, while the head of the 
bone is thus inclined, the fractured surfaces slide over one another, 
constituting a real overlapping; Figs. 62, 63 and 64, display such 
overlapping, combined with tilting over of the head of the bone, and 
with separation of the fragments superiorly. The head in these 
cases descends much more than in those before spoken of; still, even 
if unimpeded by any interlocking between the fragments, it always 
at last encounters two obstacles to its further progress ; one is the 
resistance of the capsular ligament, the other the projection of the 
lesser trochanter. Figs. 63 and 64 show this latter condition very 
plainly, although the head has been arrested some millimetres from 
the point named; and the actual shortening amounted to nine-tenths 
of an inch. I have another preparation in which the fracture is 
mixed, and somewhat further from the head of the bone; the over- 



540 A TREATISE ON FRACTURES. 

lapping is a little less marked; but on the other hand, the inclination 
of the head is a little more so; the head has here been arrested only 
by the lesser trochanter, and as it is found to be one-third of an inch 
below the great trochanter, the shortening may, according to its nor- 
mal degree of elevation, amount to two-thirds of an inch merely, or 
to a full inch; but the latter is in my opinion its maximum. 

This examination of nature enables us to estimate the various 
opinions of authors, judging them by their own facts. Sir A. Cooper 
assumes in the first place that the shortening varies from one to two 
inches ; subsequently he adds that the head is sometimes arrested at 
the lesser trochanter, and that then the shortening does not exceed 
half an inch; and among his plates may be seen a drawing of a 
fracture given to him by Mr. H. Mayo, in which the arrest of the 
head by the lesser trochanter has given rise to a shortening of one 
inch. R. W. Smith has given another specimen of quite as curious 
logic, in fixing an inch and a half as the extreme limit of the short- 
ening, while in not one of his observations did it exceed one inch.* 
Again M. Brun, from experiments upon the dead body, declares that 
he could never get a shortening of more than one-half to two-thirds 
of an inch; M. Rodet, from analogous experiments, made it out at 
most two-thirds of an inch; but this is all they could expect, if the 
head of the femur before the fracture was not more than one-third 
of an inch above the greater trochanter. 

Thus then in recent intra-capsular fractures the actual shortening 
may attain various degrees; but the double resistance of the cap- 
sular ligament and of the lesser trochanter will prevent its exceed- 
ing one inch. 

In regard to this there is one very important observation to be 
made. Quite commonly the shortening is at first either wanting or 
hardly perceptible; afterwards it suddenly appears and becomes quite 
marked, some days or even weeks after the accident. Probably in 
these cases the fragments have been kept in contact either by their 
serrations or by the resistance of the periosteum; subsequently 
some incautious movement overthrows these obstacles, already en- 
feebled by the double effect of inflammation and absorption occuring 
at the seat of injury. An old man presented pain, swelling, and im- 
pairment of motion, but no shortening, in consequence of a fall upon 
the hip. Hesitating whether to consider it a contusion or a fracture, 
I put it on a double inclined plane, and so maintained it for three 
weeks. The pain having now disappeared, and there being no 
shortening, I thought it had been a mere contusion, and removed 
the apparatus. Two days after that he had a shortening of more 

* I exclude fractures of long standing, which will come up hereafter; and also 
one case of recent fracture in which the joint had been partly destroyed by the 
suppuration. Yet in this exceptional case Smith makes out the shortening only 
an inch and a quarter, or thirty-one millimetres. 



A TREATISE ON FRACTURES. 541 

than two-thirds of an inch. I have seen another case entirely simi- 
lar to this one, and perhaps there is no other symptom of intra- 
capsular fracture which is so positive. 

Lastly, the shortening, in the conditions revealed by pathological 
anatomy, is accompanied by certain secondary phenomena which are 
worthy of our serious attention. Consider in Figs. 62 and 63 how 
much of the head and neck of the femur, in the normal state, is out- 
side of the cotyloid cavity, and serves for the abduction of the limb ; 
and compare this with what remains after the fracture. It is quite 
evident that the upper edge of the cavity, in this specimen, was 
nearly in contact with the edge of the outer fragment, which would 
strike against it on the slightest effort at abduction; while no such 
obstacle exists to adduction. But Fig. 62 shows most distinctly that 
if flexion is attempted, in order to the easy motion of the head in 
the articular cavity the femur should be carried a little outward, and 
that if flexion be combined with adduction, the outer fragment would 
almost immediately strike against the anterior border of the cavity. 

Thus is explained the increase of the pain by abduction, as pointed 
out by Louis, * and by adduction combined with flexion, as remarked 
by Sir A. Cooper. 

(5.) The riding up of the great trochanter toward the crista ilii, 
is an inevitable consequence of actual shortening ; but during life the 
thickness and sometimes the swelling of the soft parts prevent our 
clearly perceiving it, and M. Nelaton goes so far as to say that most 
commonly it does not take place. According to him the trochanter, 
going at once upward and backward, comes thus into relation with a 
more elevated portion of the crista ilii; so that the interspace between 
the two may very readily be not only as great, but even greater. 

This displacement backward of the great trochanter, observed by 
Desault, is more in the appearance than in the reality. In some 
cases the outer fragment is even thrown a little in front of the other; 
I have a specimen in which this is very evidently the case. ' When 
on the other hand it is carried somewhat backward, it is only by a 
few millimetres, and there is at the same time a rotation approximat- 
ing its posterior edge to the head of the bone and consequently to 
the iliac spine. Its anterior edge is by this movement carried a 
little backward, and from this arises the deception; but if we ex- 
amine the summit of the process, we find it rather brought nearer to 
the anterior superior spinous process, and therefore carried a little 
forward. Thus it is very certain that in all cases of shortening of 
the limb the trochanter is approximated to the iliac spine. How 
then can we explain the error of an observer like M. Ne'laton ? 
Probably from his having had to deal with extra-capsular fractures, 
in which the conditions are very different. 

* M6m. de I 'Acad. Royale de Chirurg. tome iv, p. 650. 



542 A TREATISE ON FRACTURES. 

Sir A. Cooper overlooked this displacement backward; but he 
says that the prominence of the trochanter is obliterated, seeing that 
it is carried in close to the edge of the cotyloid cavity. It is the 
posterior edge of the trochanter which is approximated to the cavity; 
but its anterior edge is quite as far from this as in the normal state, 
and we see in Fig. 62 that the interspace between the head of the 
bone and the trochanter is nearly equal in the injured to what it is 
in the sound bone. The apparent obliteration and the displacement 
backward are two different interpretations of the same phenomenon, 
namely, the rotation of the bone. If the fracture be of some weeks' 
standing, little as the buttock may have fallen away, the trochanter 
will seem more prominent than on the sound side; and this is equally 
far from the real state of the case. 

(6.) The eversion of the foot is another result of the rotation of 
the greater trochanter, much more easily comprehended. Care must 
be taken lest we confound with this the natural inclination of the 
foot, and that we do not lose sight of its essential character, viz., that 
the foot rests on the bed by its entire outer edge, the heel pointing 
directly toward its fellow. In case of any doubt, M. Gerdy has in- 
dicated a sure means of avoiding error, which is to increase the rota- 
tion until the toes point outward and a little backward; this being 
almost impossible, if the pelvis remains fixed, and the cervix femoris 
is unbroken.* 

The eversion is not constant. In the first place there are numer- 
ous cases in which it is absent during the first few days, only pre- 
senting itself at a period more or less advanced. In other cases the 
foot maintains its normal position throughout ; and lastly there are 
cases in which it falls inward; of this A. Pard and J. L. Petit have 
each given an instance; Desault thinks it occurs in about one case 
out of every four, and I for my part have several times seen it. 
Guthrie, it is true, denies that it can take place in recent fractures 
within* the capsule, but Stanley proved by an autopsy that one case 
was entirely intra-capsular in which, from the very first, the foot 
was turned inward. f This inversion occurs to quite as marked a 
degree as the eversion; the foot lies on the bed by its whole inner 
edge, and in the subject of Fig. 67 this fact, combined with the 
decided adduction of the limb, led me into error, giving me the idea 
at first of a luxation of the hip. 

What is the origin of these differences? Rotation outward is quite 
generally accounted for by muscular action; but hitherto rotation 
inward has not received any such explanation. In 1833, having 
found the foot inverted in a fracture of the neck of the femur, I 

* Gerdy, Obs. et Reft, sur lesfract. du col dufimur ; Arch. Gin. de Midecine, 
1834, tome vi. p. 371. 

f Guthrie, Medico- Chirurgiccd Transactions, vol. xiii, p. 103; Stanley, ibid. 
p. 508. 



A TREATISE ON FRACTURES. 543 

ascertained that it was easily everted and again inverted at will, and 
that it remained as readily in one position as in the other; whence I 
concluded that whatever inclination is given to the part upon the 
supporting plane, it keeps by its own weight ;* M. Mercier sub- 
sequently made the very just remark that in carrying the patient 
his limbs are generally kept together, and the sound foot hinders 
the one on the injured side from turning inward, leaving it to follow 
its natural inclination and to gravitate outward. 

A deeper study of the facts has greatly modified my views in re- 
gard to this point. We must first determine by what mechanism the 
foot is turned. When the fragments are held in place either by their 
serrations or by the periosteum, the limb may be rotated either in- 
ward or outward at pleasure, but only within the normal limits of this 
motion ; there is no displacement at the seat of fracture, nor distor- 
tion of the limb. Still, even then this freedom of motion does not 
exist after the first or second day; the muscles contract around the 
injured joint, preventing motion just as in an ordinary contusion or 
arthritis. Sometimes, when the limb is left to its own weight, this 
by its continuous action at last stretches the bands which hold the 
fragments together; the outer fragment inclines backward; there is 
then angular displacement, and a rotation of the foot beyond the 
normal limits : which explains those cases in which the foot, at first in 
good position, inclines more and more until it falls over completely. 

But it is far mure common to meet with this rotation immediately 
after the accident, when it is a certain sign of actual displacement 
due to the fracturing cause. In the case of rotation inward observed 
by Stanley, the synovial membrane and periosteum were torn through 
completely, except in front ; whence we may infer, in spite of the 
want of further details, that the trochanter had been carried so 
strongly forward as to make between the two fragments an angle 
salient posteriorly. As to eversion, the proofs are abundant. I 
have already alluded to a specimen in which the fragments are sepa- 
rated above so as to let the head of the bone down below the level of 
the trochanter ; there is likewise in front a separation of over one- 
third of an inch, and the outer fragment seems to project a little in 
this direction, while posteriorly it is driven into the spongy texture 
of the inner one. I have another specimen in which it is, on the 
contrary, the inner fragment which overlaps the other in front by 
nearly one-third of an inch, and which posteriorly is buried in its 
spongy tissue ; and as at the same time there is considerable short- 
ening, the result of this double displacement has been to bring the 
lesser trochanter below the head of the femur. 

The Muse'e Dupuytren contains several analogous preparations. It 
is evident that in such a case it would be impossible to rotate the 

* Gazette Mtdtcale, 1833, p. 318. 



544 A TREATISE ON FRACTURES. 

foot inward, without overcoming the impaction of the fragments, and 
employing a very considerable degree of force. 

Are there not nevertheless some exceptional cases, in which, the 
fragments being completely separated, and in no way hindered from 
inclining at an angle in either direction, rotation is possible either 
inward or outward, and to any degree ? This is probable, but I have 
no facts by which to prove it. 

Eversion of the foot is almost always accompanied by two other 
phenomena, viz.: a projection of the anterior part of the cervix for- 
ward, and a narrowing, sometimes to an extreme degree, of the hol- 
low between the head and the great trochanter posteriorly. These 
are easily observed in anatomical specimens, and I have sometimes 
been able to detect them during life. 

(7) Crepitation is in these cases elicited with difficulty. Sir A. 
Cooper says that we may obtain it by drawing the limb down to its 
natural length, and then rotating it, especially inward. It may 
sometimes be perceived also, he adds, by placing the patient upright 
upon his sound limb, and then giving a rotary motion inward to the 
one affected, which will be elongated by its own weight. I apprehend 
that this direction, to stretch the limb, is dictated by an erroneous 
theory, with a view of bringing the fractured surfaces in contact; 
while in fact they have never completely abandoned one another. 
Nothing, however, need prevent our testing it practically ; I can only 
say that for my own part, in cases in which the diagnosis has been 
incontestably verified- by dissection, I have never during life suc- 
ceeded in producing crepitus. 

What now is the course, and what are the terminations of this 
fracture ? We say first, that the most general fact concerning it 
is the want of bony union between the fragments. This has been 
long contested, and has long been accounted paradoxical; it took 
Sir A. Cooper no less than twenty years to effect its definite admis- 
sion by science. He explains this want of consolidation upon three 
grounds : (1) the riding up of the outer fragment, preventing coap- 
tation ; (2) the excessive secretion of synovial fluid, the inevitable 
consequence of the injury to the joint, and the effect of which is to 
separate the fragments by pushing the outer one farther out ; (3) 
lastly, the low vitality of the inner fragment, which receives its nutri- 
ment only through the scanty vessels of the round ligament, and of 
that portion of periosteum between the fragments which may remain 
unbroken. This last reason is assuredly the principal one. 

There have, however, been reported quite a number of instances 
of bony consolidation. Amesbury has collected four such, from 
Langstaff, Brulatour, Chorley, and Field ; I have already cited those 
of Swan and Stanley; M. Chassaignac ascribes another to Van 
Houte ;* one is quoted from Adams by R. W. Smith; and lastly, the 

* Chassaignac, ThZse inaug., Paris, 1835. 



A TREATISE ON FRACTURES. 545 

Muse*e Dupuytren contains three specimens which have been so de- 
scribed. This limited number of cases, carefully brought together 
ever since the question was raised, shows how rare bony union must 
be ; but it must be added that even in regard to most of these there 
is too much ground for uncertainty. Thus the four cases collected 
by Amesbury, as well as that of Adams, much more closely resemble 
rachitic alterations of the cervix than veritable fractures ; I must 
say the same of Nos. 177 and 189 in the Muse'e Dupuytren ; and it 
suffices to study the beautiful drawings given by Sir A. Cooper of 
some of these alterations, to put us on our guard against any so- 
called consolidation with shortening and deformity of the head and 
neck of the bone. When a fracture unites, the fragments do not 
undergo such enormous losses of substance as we should have to 
admit in the neck of the femur ; and in Swan's case, which Sir Ast- 
ley Cooper himself acknowledged as an instance of bony union, the 
neck of the bone had not changed its form. It was so also in Stan- 
ley's case ; and lastly, one femur, (No. 188,) in the Muse'e Dupuy- 
tren, has lost nothing either in form or volume except as the result 
of a very trifling displacement. I admit that these three examples 
demonstrate quite positively the existence of consolidation ; but I 
cannot say the same of any of the rest. 

[Dr. R. D. Mussey, of Cincinnati, in an article on Fractures of the 
Keck of the Thigh-bone, published in Hays' American Journal for 
April, 1857, gives Jive cases of intra-capsular fracture, four of which 
he himself treated and subsequently dissected, the fifth being without 
history ; another, without history, is almost entirely intra-capsular, 
but not quite. In three of Dr. M.'s cases union took place by bone, 
and in one by fibrous tissue ; in the fifth specimen it was ligament- 
ous, and in the sixth bony. 

Dr. Henry H. Smith has remarked, in his text-book on surgery, 
that in all the cases of bony union within the capsule, the fracture is 
seated very close to the head of the femur ; assigning as an expla- 
nation of this fact the more ready nutrition of a small fragment by 
the vessels running along the ligamentum teres, and the greater 
chance of the periosteum remaining intact than when the fracture is 
nearer the trochanters.] 

Now let us see what are the results of experience as to the course 
of these fractures. Slightly as the periosteum and synovial mem- 
brane may be torn, there is an effusion of blood within the joint ; 
soon after this, inflammation is set up to a greater or less degree, 
and gives rise to an abundant synovial secretion, with shreds of fibrin 
floating in it. Subsequently absorption takes place ; and at last, 
according to the degree of contact and of the vitality of the frag- 
ments, they are found to be united by fibrous or fibro-cartilaginous 
tissue, or perhaps merely by fibrous bands of greater or less length; 
or, finally, union may be entirely wanting, the fractured surfaces re- 

35 



546 A TREATISE ON FRACTURES. 

maining quite unconnected. Figs. 62, 63 and 64 represent a frac- 
ture dating back six months and a half; at those points where the 
fractured surfaces were in contact, they are joined together through 
the intervention of fibro-cartilage ; lower down the inner fragment, 
in relation with the inferior wall of the cervix, is attached to it by 
scattered fibrous bands; and lastly, at the circumference there is 
found a very dense fibrous tissue, continuous externally with the sub- 
synovial periosteum, and below with the capsule itself, both the latter 
membranes being reddened and thickened. Fig. 67 shows union by 
longer and much less resisting fibrous bands ; and in Fig. 6b there 
has been no union at all. 

It is very remarkable that here the periosteum covering the two 
fragments does not, as in ordinary fractures, throw out any ossific 
matter. There are almost never found near the fracture those bony 
deposits attributed to the provisional callus ; and when, by chance, 
they are met with, they belong almost exclusively to the outer frag- 
ment. It is the capsular ligament which is here most efficient in 
maintaining the relations of the broken ends, in default of their di- 
rect union; frequently it becomes thickened, assuming a consistence 
like that of cartilage ; Colles saw it in one instance a quarter of an 
inch thick throughout, and in some places half an inch. It may even 
undergo osseous transformation ; in one of R. W. Smith's observa- 
tions, a concave plate of bone, three inches in length and one inch 
wide, occupied the anterior portion of the capsule ; Langstaff has 
described a similar specimen ; and No. 135 in the Muse'e Dupuytren 
affords a remarkable instance of a like deposit. Lastly, I have re- 
ceived from M. Teissier a specimen, already described by M. Man- 
zini, in which a bony mass of nearly seven inches in circumference 
by two or three in thickness, surrounds at once the trochanter and 
the two inter-trochanteric lines, as if to give the pelvis a point 
d'appui upon the femur. 

A different action goes on between the two fragments, especially 
when there is no union of any kind. In the specimen represented 
in Fig. 62, all that part of the broken surface of the outer fragment 
which is above the level of the other is coated with a kind of white, 
smooth cartilage, like that of incrustation. Lower down, where the 
two fragments look toward one another without being in contact, 
there are on the outer one bright red granulations, doubtless the 
commencement of an incrusting cartilage. Neither granulations nor 
cartilage are to be seen on the inner fragment. After having traced 
in this specimen the first two stages of the process of incrustation, 
by granulations and cartilage, the final result is seen in Figs. 6b and 
67, representing very old fractures ; the outer fragment is covered 
with osseous plates, thick, smooth and ivory-like; the inner one 
shows nothing of the kind. 

Sir A. Cooper has asserted, and many other writers have followed 



A TREATISE OX FRACTURES. 547 

him, that the portion of the neck which remains attached to the 
trochanters undergoes an absorptive process by which it is in great 
measure destroyed. This is a capital error. Certainly, in glancing 
superficially at the outer fragment in Fig. 65, and especially in Fig. 
67, one is struck with the almost total disappearance of any promi- 
nence resembling the cervix ; but if the thickness of the bone at this 
point be accurately measured, it is easily seen to be not at all dimi- 
nished ; and it will be found that, although the projection of the cervix 
is rounded off at its upper angle, its thickness is rather increased 
below by the addition of the eburnated plates above alluded to. 

It is quite otherwise with the inner fragment. In Figs. 62 and 63 
the beginning of its absorption may be observed; and in the subse- 
quent figures this is seen to reach a very marked degree. Fig. 65 
shows the head hollowed out by the rounded extremity of the outer 
fragment; but in Fig. 67 it presents, on the contrary, irregular pro- 
jections. But in order to give a better idea of the progress of this 
wasting I have accurately measured in these three specimens the 
thickness, through the head and the great trochanter, and have 
found : 

Fig. 62, femur in the normal state - 91 millimetres (3^ inches.) 

" " with the fracture - 91 " " 

Figs. 65 and 66 86 " (2 T 9 o inches.) 

Figs. 67 76 " (2^ inches.) 

"Why should there be such a difference between the two fragments? 
I have no hesitation in ascribing it to the difference in their vitality. 
The outer fragment, highly vitalized, resists, grows, and hardens 
beneath the pressure; the other wastes away.* There is seen in the 
section of the head of a femur represented in Fig. 63, a light-colored 
spot answering to its upper portion, where the wasting is most marked. 
This spot was yellowish in the fresh specimen, and much harder than 
the rest of the fragment, which was of a beautiful red color ; it was 
harder even than the spongy texture of the outer half of the trochan- 
ter, which presented nearly the same yellow color. This was so marked, 
that I could not divest myself of the idea of a partial necrosis ; and 
without wishing to assert that this portion of the bone was totally 
altered, I think at least that its nutrition was already insufficient, 
and that to this fact was owing its slight resistance either to wear or 
to absorption. 

Lastly, at the same time that the inner fragment wastes away, the 
riding up of the femur is increased by the weight of the body and 

* Brunninghausen has even reported a case in which the head of the femur 
entirely disappeared in consequence of a fracture of the cervix, and R. W. Smith 
credits Banco with another of the same kind; but I think there has been some 
error here. See Brunninghausen, Sur la/r. du col du femur; Biblioth. Germa- 
nique, tome hi, p. 114. 



548 A TREATISE ON FRACTURES. 

by the action of the muscles ; if the capsular ligament is not thick- 
ened or ossified, it at length becomes stretched, and the head of the 
bone gradually passes down below the lesser trochanter. The com- 
mencement of this descent is seen in Figs. 6b and 6Q; the lesser 
trochanter has been wasted by the friction, covered with an eburnated 
layer, and incased in a synovial membrane. But this friction was 
only sustained during flexion ; at other times the head remained at a 
higher level ; the capsule itself has been intact below, and there the 
shortening has amounted in all to only an inch. In Fig. 67 the 
descent has been inordinate ; the lesser trochanter has entirely disap- 
peared, and is blended with the eburnated surface of the outer frag- 
ment; and the tendon of the psoas muscle presents a bony plate 
supporting the head of the bone anteriorly. The real shortening 
was nearly two inches ; but the thigh being at the same time slightly 
flexed and excessively adducted, and the pelvis drawn up on the 
affected side, the whole amount of shortening was hardly less than 
three and a half inches. Sir Astley Cooper quotes from Langstaff 
the case of a man who was obliged, in order to equalise the two limbs, 
to wear a sole four inches thick. 

Hence we see what difficulties the patient must meet with in trying 
to use the limb. Except in the very rare cases in which the fragments 
are kept in contact by ossific callus or by strong fibrous connections, 
the femur rides up, and the limb becomes shortened until the head 
bears against the lesser trochanter; indeed it is fortunate if the 
shortening goes no further. The patients are unable to walk without 
support; some can get along with a stick; many require a crutch; 
others need both a stick and a crutch, or even two crutches ; and 
among these latter, many carry the injured limb as a mere dead 
weight, being unable to rest on it in the slightest degree. The pelvis 
being commonly drawn up on this side, the limb is more or less 
adducted by its own gravity, and generally is also slightly flexed. 
But I would call attention especially to the motions of the hip, which 
I have studied with some care both in the living and in the dead 
subject. 

The thigh may in general be passively moved on the pelvis with 
great freedom; it may be flexed, extended, carried outward or in- 
ward, or even rotated; and although undoubtedly all these move- 
ments are somewhat more limited than those on the sound side, still 
they do take place, either in the normal articulation or in the false 
joint, the pelvis remaining fixed. The will, on the contrary, can hardly 
command any mobility at all ; most of the motion in this case is in 
the lumbar portion of the spinal column; in some instances it takes 
place wholly there, the muscles of the thigh serving only to fix the 
pelvis, and the limb having lost one joint. So that, what is remark- 
able, in these latter cases the neck of the bone has both a true and 



A TREATISE ON FRACTURES. 549 

a false joint, and vet it is as useless for voluntary motion as if it 
were firmly anehylosed. 

Hence the muscles of the hip, rendered almost entirely inactive, 
lose their volume; I have seen the gluteus minimus in a state of fatty 
degeneration, and the tendon of the psoas ossified in its groove. 
Thus the buttock becomes flattened, or even hollow; the trochanter 
seems more prominent, and is evidently approximated to the iliac 
crest, more especially to the anterior superior spine. In a specimen 
in my possession, comprising the pelvis and both femurs, when the 
pelvis rests exactly, upon the middle portion of the sacrum the tro- 
chanter of the sound side is nearer the ground by half an inch than 
that of the other. The rest of the limb always participates more or 
less in this atrophy. 

Guthrie quotes a case from Langstaff, in which the foot was at first 
everted, but was brought inward when the patient began to use his 
limb. But this was an exceptional instance ; and I have dissected 
several intra-capsular fractures of long standing, in which the ever- 
sion of the foot remained. 

I shall not dwell here upon the diagnosis, which can be better and 
more completely discussed in connection with extra-capsular frac- 
tures. 

The prognosis is always grave ; with very rare exceptions, a patient 
with intra-capsular fracture will be lamed for life, and sometimes 
even lose the use of his limb entirely. There is besides at the outset 
a still greater danger to be warded off. Of the twenty-three sub- 
jects from which the specimens in the Richmond Hospital Museum 
were obtained, six died at from the seventh to the seventeenth day, 
with all the symptoms of low inflammatory fever, occurring sooner or 
later after the accident. The period of life has but little to do with 
this result ; three of these cases were above seventy or even eighty 
years, but the three others were below fifty-one. One more patient, 
forty-one years old, should be added, who died on the thirtieth day 
in consequence of a very large abscess in the joint, complicated with 
acute osteitis in the femur ; so that death seems to have selected in 
preference the more youthful patients. 

The treatment is very far from being fixed. 

The ancient school, still represented by Boyer, held that the want 
of union in these fractures depended solely on want of contact and 
of sufficient apparatus; whence they attached great importance to 
reduction, and contrived a variety of plans for making permanent 
extension. 

Another school, with Sir Astley Cooper at their head, regarding 
consolidation as impossible in the immense majority of cases, aban- 
doned all attempts at reduction and all forms of apparatus. "I 
should," says Sir Astley, "if I sustained this accident in my own 
person, direct that a pillow should be placed under the limb through- 



550 A TREATISE ON FRACTURES. 

out its length, that another should be rolled up under the knee, and 
that the limb should be thus extended for ten days or a fortnight, 
until the inflammation and pain had subsided. I should then daily 
rise and sit in a high chair, in order to prevent a degree of flexion 
which would be painful; and walking with crutches, bear gently on 
the foot at first; then gradually more and more, until the ligament 
became thickened, and the muscles increased in their power. A 
high-heeled shoe should be next employed, by which the halt would 
be much diminished. Our hospital patients," he goes on to say, 
"treated after this manner, are allowed in a few days to walk with 
crutches ; after a time a stick is substituted for the crutches, and in 
a few months they are able to use the limb without any adventitious 
support." 

Sir Astley has nevertheless duly acknoivledged the danger of this 
course on account of the uncertainty of the diagnosis. "In every 
case, however," says he, " in which there is the smallest doubt whether 
it be a fracture within or external to the ligament, it will be proper 
to treat the case as if it were the fracture which I shall hereafter 
describe, and which admits of ossific union." 

This might be sufficient in practice, since in fact our uncertainty 
never is completely removed. But even if the surgeon had the as- 
surance which is wanting, I say that besides bony union there are 
other objects to be aimed at. It is not a matter of indifference whe- 
ther the patient has a very slight or a very considerable shortening; 
and we can only hope to regulate this by keeping up the interlocking 
or the interpenetration of the fragments, by maintaining the sound 
condition of the periosteum, and by favoring union by a fibrous tis- 
sue as short and thick as possible ; now this triple indication cannot 
be fulfilled except by immobility and a good position of the limb. It 
is well also to correct the inclination of the foot, whether outward 
or inward. Hence there is, within certain limits, a necessity for 
making and maintaining reduction. 

We should never make reduction with the view of elongating the 
limb. If the shortening is slight, we should by so doing risk the 
disengagement of the fragments ; if it is considerable, the periosteum 
must have been a good deal torn, and the reduction, which must be 
made by means of permanent extension, would in no way promote 
the impossible union of the entirely isolated fragments. All that 
can prudently be done is to restore the proper direction of the foot, 
at the same time raising the trochanter, and pressing carefully upon 
the anterior face of the cervix femoris. It would be better even to 
leave the foot everted, than by the employment of force to risk de- 
stroying the mutual penetration of the fragments. 

Our attempts at retention should be confined to keeping the foot 
in proper position, preventing any increase of the shortening, and 
insuring as much as possible the immobility of the limb. The double 



A TREATISE ON FRACTURES. 551 

inclined plane, with a solid foot-board, has seemed to me to offer the 
greatest advantages and the fewest inconveniences. For the rest, 
although union, whether fibrous or bony, requires but forty or fifty 
days, the apparatus should always be left on somewhat longer. 

The severe local pains should be allayed by emollient cataplasms. 
Sir A. Cooper apprehends in these cases some injury to the general 
health from prolonged confinement. I have before shown, in speak- 
ing of one of the most alarming of these symptoms, — sloughing over 
the sacrum, — that they are never brought on by mere want of mo- 
tion, [ante, p. 236.) As to the general affections which may give 
rise to them, and which too often destroy the life of the patient, they 
commonly develop themselves almost immediately after the accident, 
and rest in bed, so far from causing them, is one of the essential and 
unavoidable conditions of their treatment. 

If, lastly, after the time required for either bony or fibrous union, 
the first attempts at walking made by the patient augment the short- 
ening to any notable degree, an entirely new indication is presented, 
which I believe was first pointed out by me ; it is to surround the 
pelvis below the iliac spines with a well-padded leather girdle, strongly 
fastened with buckles, to obviate as much as possible the riding up 
of the irreat trochanter. 



§ II. — Extra- Capsular Fractures of the Cervix Femoris. 

In this form of fracture the neck of the bone is generally detached 
at its base, along the oblique line running in front from one trochan- 
ter to the other, and along the inner edge of the corresponding line 
posteriorly. This is in some sort its normal type; but it may be 
seated nearer to or farther from the capsule; and hence arise two 
varieties, both of which are, however, quite rare. 

"When the seat of the fracture is a little farther inward, the case 
hardly calls for any special mention ; only the insertion of the cap- 
sule into both the fragments will prevent any very considerable sepa- 
ration of them. But when it is located farther outward, it divides 
the greater trochanter, which then forms a part of the upper frag- 
ment; Guthrie, R. W. Smith, Mercier, Michon, and Nivet have met 
with cases of this kind.* 

Besides these differences in their seat, extra-capsular fractures may 
be partial or complete, single or multiple. 

A too superficial examination of fractures of long standing led 
Adamsf to a belief in incomplete fractures, in which, says he, the 

* Guthrie, Medico- Chir. Transactions, vol. xiii. p. 103; R. W. Smith, op. n't., 
obs. 30; Mercier, op. dt., obs. 3; .Michon, Bulletin de la Soc. Anatomiqae, 1835, 
p. 37; Xivet. ibid., 1836, p. 182. 

t Adams. MCm. 8UT Xafrad. incotopltts du col du femur ; Gazette Medicale, 
1835, p. 641. 



552 A TREATISE ON FRACTURES. 

compact tissue of the upper wall of the cervix femoris presents no 
change unless it be that the entire neck has assumed a horizontal 
direction; while the inferior wall, evidently broken, is driven into 
the spongy tissue of the outer fragment, so as to make with the 
inner wall of the shaft something like the letter T. [See Fig. 71.] 
According to this, Figs. 70 and 71 present all the characters of par- 
tial fracture; but we need only look at the inclination inward of the 
great trochanter to be convinced that there is something more than 
this; and the study of the specimens themselves would remove all 
doubt on the subject. I know of but one instance of incomplete 
extra-capsular fracture ; it was found by M. Tournel in an old man 
of eighty-five, who had had a fall upon his buttocks. He died three 
months and a half afterwards ; the autopsy revealed a long crack in 
the bone, the upper part of which corresponded to the digital fossa 
within the great trochanter, and which in front and behind was pro- 
longed into two fissures terminating externally a little below the 
level of the lesser trochanter. It was then, contrary to Adams's 
hypothesis, the inferior wall of the cervix which had resisted.* 

[In the paper of Dr. Mussey, alluded to in a note to the preced- 
ing section, mention is made of a specimen shown by Dr. J. B. S. 
Jackson before the Boston Society for Medical Improvement, in 
which the "fracture, commencing at the junction of the head with 
the upper part of the neck" of the right femur, "extended to within 
about the fourth of an inch, or a little more, of the periosteal surface 
of its inferior and internal wall. * * * * The patient, a 
healthy man of forty-two years, fell through two stories of a build- 
ing upon a hard floor, fracturing his backbone and the middle third 
of the shaft of the right thigh-bone, nearly in a transverse direc- 
tion, complicated with another fracture extending upward from this, 
splintering the bone for several inches." In the outline sketch ac- 
companying the report, the first-named lesion looks very much like 
an incomplete extra-capsular fracture of the cervix femoris.] 

Single complete fractures of this part are themselves extremely 
rare. The observation of M. Mercier, already quoted, is one in- 
stance, and to this should perhaps be added that of Michon ; both, 
which is remarkable, belong to the variety in which the great tro- 
chanter forms a part of the upper fragment. But as for what I 
have called the normal type, I know of but a single case of an al- 
most single fracture, that is to say, one without any other complica- 
tion than two small fissures of the trochanters. f Others have indeed 

* Archives G6n. de Me'decine, 1837, tome xiv, p. 77. The author adds that 
the fracture was at once intra and extra-capsular, but this is not in accordance 
with his description. 

f R. W. Smith, op. cit., obs. 34. [The term single is the only word which 
answers to the French " simple" as applied to fractures ; its meaning in this use 
will be readily perceived.] 



A TREATISE ON FRACTURES. 553 

been cited, but they were in long-standing cases, and sufficient atten- 
tion was not paid to the condition of the great trochanter. 

Multiple fractures are therefore beyond comparison the most com- 
mon, and present themselves in two principal varieties. In the first, 
the great trochanter is broken off by itself at the same time with the 
cervix, and constitutes a third fragment ; in the other the lesser tro- 
chanter is likewise separated, forming a fourth fragment. Then there 
are cases in which the third fragment is formed by the lesser tro- 
chanter, the greater forming part of the upper piece, (Guthrie;) 
others in which both trochanters are found connected with the same 
piece, as in the specimen represented in Fig. 71; and others again, 
in which the great trochanter is splintered or crushed. But these 
different circumstances have only a secondary interest, and are sub- 
ordinate to the two chief complications, fracture of the greater tro- 
chanter by itself, which is the most common, and double fracture 
involving both trochanters. 

Lastly, the difference of aspect between recent and long-standing 
fractures has misled R. "TV. Smith into distinguishing between ordi- 
nary extra-capsular fractures and such as are attended with penetra- 
tion, or impacted. I assert, on the contrary, that all fractures in 
which the cervix femoris is detached at its base are impacted ; and 
that this impaction is entirely wanting only in those exceptional cases 
in which the great trochanter forms part of the upper fragment. 

Fig. 68 affords an example of extra-capsular fracture, with the 
trochanter broken off also; the bone is seen from behind, and the 
fragments drawn as in their natural position, in order better to show 
the direction of the double fracture. Nothing, either in the draw- 
ing or in the dried specimen, in which all the fragments are loose 
and disunited, indicates any penetration; but in the subject, the 
head of the femur was strongly inclined inward ; all the lower part 
of the neck seen outside the capsule was buried in the thickness of 
the lower fragment, the cutting edge of which had stripped up and 
turned inward the periosteum, and in Fig. 69 are seen two isolated 
bits of the spongy tissue crushed by this penetration; lastly, the 
great trochanter, involved in the inclination of the head of the bone, 
was itself drawn strongly inward, lying as it were upon the top of 
the shaft. Had consolidation occurred, we should have had very 
nearly the result represented in Fig. 70: the head inclined down- 
ward ; the great trochanter laid upon the summit of the shaft, in 
such a way that its inner face is in the same vertical line with the 
inner face of the shaft, and lastly the inferior wall of the cervix 
buried in the thickness of the lower fragment. 

But the penetration itself presents some variations which it will 
be well to note. In general it occurs only below and behind, the 
fragments even remaining a little separated in front; then the lower 
fragment, consisting of the diaphysis, always projects more or less 



554 A TREATISE ON FRACTURES. 

in front of the upper, and the result is that the head and neck of 
the bone are not only inclined downward, but backward also. Some- 
times the penetration takes place directly and en masse, the anterior 
wall of the cervix being engaged as well as the posterior; we even 
see some very rare cases in which the superior wall seems also to 
share in it, when the head is inclined neither backward nor down- 
ward; at least its inclination is reduced to almost nothing. Lastly, 
the penetration may amount to only a few millimetres, or it may in- 
volve almost the whole lower wall of the cervix ; in Fig. 71 the lat- 
ter is nearly in contact with the outer wall of the diaphysis. It has 
even been stated that sometimes the base of the cervix pierces through 
the trochanter, coming out below the bursa lining the tendon of the 
gluteus maximus, after having caused a comminuted fracture of the 
above-named process;* but this results from a misinterpretation of 
facts. In the only case in which R. W. Smith has observed anything 
similar to this, it is evident from the drawing that there is merely an 
exposure of a very small portion of the cervix, behind and not out- 
ward, by the displacement of the trochanteric fragment. 

Extra-capsular fractures are less common than intra-capsular ; but 
like them they are more frequently met with in women than in men, 
and especially affect persons over fifty years of age. Of seventeen 
extra-capsular fractures in the Richmond Hospital Museum, the his- 
tories of which are known, nine were in women ; only one was taken 
from a person less than fifty years old. Figs. 68 and 70 represent 
specimens from men of fifty-four and eighty-seven years respectively; 
I am not informed on this point concerning Fig. 71. 

The most common determining cause is a fall upon the great 
trochanter, either from a great height or with great violence, whether 
from the -standing position or from off a chair. Next come blows on 
the same process, which however are much more rare; thus Desault 
saw a case in which the cause was the kick of a horse. Direct blows 
are on the contrary the best, and perhaps the only means of pro- 
ducing this fracture in the dead body ; M. Rodet has even attempted 
to establish an exact correlation between this species of cause and 
this species of fracture. I have shown when speaking of intra-cap- 
sular fractures that this theory was too absolute; and we have just 
seen that in M. Tournel's case of incomplete fracture the cause was 
a fall on the buttocks. But the case which most directly contradicts 
the theory in question is that communicated by Powell to Sir A. 
Cooper; a woman eighty-three years of age was walking in her 
chamber, came near losing her balance, made an effort to save her- 
self, and in consequence of this effort, without any fall, had an 
extra-capsular fracture. It would be difficult in this case not to re- 

* Robert, M6m. sur les fract. du col du femur, accomp. de penetration; 
Rapport d I'Acad. de Medecine; Bulletin de VAcadtmie, tome x, p. 322. 



A TREATISE ON FRACTURES. 555 

cognise muscular action; it shows, moreover, from what slight causes 
the fracture may sometimes result. 

How do these determining causes act ? The idea which first pre- 
sents itself, and which has misled many authors, is that the external 
violence tends to obliterate the angle between the neck and shaft of 
the bone, the lesion thus commencing in the lowest of the bony 
fibres. Pathological anatomy completely refutes this hypothesis. 
In the only case of partial fracture known to us, the lowest fibres 
were the only ones uninjured; in nearly all complete fractures the 
penetration is greatest below, showing that the force has acted rather 
so as to diminish than so as to increase the angle; and in no case 
has the angle been seen to be increased in any way whatever. In 
some instances there seems to have been direct crushing ; but in a 
good many others, the separation anteriorly seems to denote that the 
force has acted by impelling the great trochanter backward. I have 
shown in connection with intra-capsular fractures that this latter is 
the appropriate result of falls on the side, on account of the natural 
inclination of the process alluded to; M. Robert has found an addi- 
tional reason in its anatomical arrangement. The neck of the bone 
is almost directly continuous, anteriorly, with this process; while 
posteriorly it is separated from it by a much deeper depression. 
The axis of the neck therefore answers only to the anterior third of 
the trochanter, and a fall directly upon this process would necessarily 
drive it farther backward, when it is unsupported, thus making the 
two fragments form an angle salient forward. 

The symptoms as stated by authors are nearly the same as those 
of intra-capsular fracture: pain, swelling, loss of power in the limb, 
shortening, eversion of the foot, and crepitation. Let us examine 
these in order. 

(1.) The pain, according to Sir A. Cooper, is severer than in 
intra-capsular fracture; I think I have reduced this assertion to its 
proper value. M. Robert has added, with more truth, that it is more 
external, and that in fact pressure upon the great trochanter acts 
directly upon the fracture ; but unfortunately this pressure likewise 
occasions pain in the intra-capsular variety. 

(2.) The swelling is generally more marked than in intra-capsular 
fracture, and is moreover frequently combined with ecchymosis at 
the outer portion of the hip and of the thigh. It is important to 
note, however, that cases are not very rare in which there is no 
ecchymosis. 

(3.) The loss of power in the limb is less, according to M. Robert, 
than in intra-capsular fracture, and the impaction allows the patient 
to raise the whole limb, and even to walk immediately after receiving 
the injury. Sir Astley Cooper, on the contrary, asserts that the 
abnormal rigidity of the joint, due to the pain, hinders flexion and 
extension. These different phenomena will indeed present themselves 



556 A TREATISE ON FRACTURES. 

in different cases, and even succeed one another in the same case; 
but I have shown that this is true also of the intra-capsular form, 
and M. Robert himself has quite recently presented an exemplifica- 
tion of this to the Societe de Chirurgie. 

(4.) Shortening would seem to be a constant phenomenon in this 
lesion, but it occurs in very various degrees, by reason chiefly of the 
mechanism to which it is due. 

When the trochanter forms a portion of the upper fragment, this 
rides up outward so as to lessen the angle between the shaft and the 
neck of the bone; all the shortening depends upon this movement, 
by which the head of the bone is tilted downward. If the fracture 
is a single one, it cannot amount to much; but it increases in pro- 
portion to the number of splinters. Guthrie has found it half an 
inch ; M. Nivet has estimated it at eight or ten lines ; R. W. Smith 
at an inch and a half, but he probably confounded somewhat the real 
shortening and the apparent. 

In ordinary fractures, as has been stated, the inner fragment is 
sometimes driven directly into the outer one; the shortening, de- 
pending solely on the degree of this penetration, is then always very 
limited. R. W. Smith has described and figured a case of this kind 
in which it amounted to only a quarter of an inch. In an analogous 
specimen, No. 166 in the Musee Dupuytren, the head seems at first 
sight to have maintained its usual level; but on measuring the ver- 
tical distance between its level and that of the base of the great 
trochanter, this is found to be but an inch and three-fifths, from 
which may be inferred a shortening of one-third to one-half an inch. 

But most commonly the shortening is due to the combination of 
these two elements, the tilting of the head and the penetration of the 
cervix; varying according to the degree of each. The former espe- 
cially is only limited by the lower edge of the fracture, preventing 
the neck from descending any farther. When the lesser trochanter 
remains intact, it affords a point cfappui to the cervix, just as it 
does to the head in intra-capsular fracture. But in order to rightly 
estimate the shortening thus produced, it must not be forgotten that 
the head of the femur is normally more or less elevated above the 
trochanter in different subjects, and especially at different periods of 
life. Thus in both Figs. 68 and 70 the neck has been arrested by 
the lesser trochanter. But in the former case the patient was eighty- 
seven years old, and the head was above the trochanter by only one- 
third of an inch; the actual shortening was only half an inch. In 
the latter the age of the patient was fifty-four at the time of the in- 
jury, and seventy at the time of his death ; the shortening amounted 
to a full inch. 

When lastly the lesser trochanter is itself detached, the head of 
the bone, being no longer arrested by it, descends much farther, even 
to the extreme limits of the fracture. In the specimen represented 



A TREATISE ON FRACTURES. 557 

in Fig. 71, a large fragment comprising both trochanters was broken 
off, and carried backward and downward; the cervix is seen to have 
descended until it brought up against the anterior wall of the shaft; 
and the actual shortening could not have been less than one and a 
half to two inches. 

Hence we see the incorrectness of Sir A. Cooper's assertion, that 
the shortening does not exceed three-quarters of an inch. M. Bonnet 
has verified by dissection shortenings of an inch to an inch and a 
half, and R. W. Smith saw them as great as an inch and a half to 
two inches. 

A more difficult question is whether in these fractures the shorten- 
ing is always the same. In Sabatier's first observation, which seems 
to have been a case of extra-capsular fracture, it is stated that there 
was no shortening until several days after the fracture. It may 
readily be conceived that any accidental movement, or even mere 
muscular contraction, would suffice to increase the tilting of the head 
of the bone, and with it the shortening; but this could not then take 
place to any great degree, and in order that Sabatier's case should 
have its full weight he should have made the nice distinction between 
real and apparent shortening. 

(5.) The eversion of the foot in these cases is explained by the 
impaction of the posterior wall of the inner fragment, which is as- 
suredly due to the direction of the external violence; a fall on the 
trochanter while the foot was inverted, would in the same way give 
rise to the opposite condition. Often this distortion is so marked 
that it cannot be corrected, and the foot restored to its normal posi- 
tion, without using a considerable degree of force; but sometimes the 
limb obeys the slightest manipulation. The subject of Fig. 68 had 
the foot turned outward, but it could be easily rotated inward, and 
on the other hand in one of R. W. Smith's cases the foot was turned 
inward, but could with equal facility be rotated outward. 

All this has reference to ordinary cases; but when the greater 
trochanter forms a part of the upper fragment, Guthrie has imagined 
that diversion was unavoidable, seeing that the majority of the ex- 
ternal rotator muscles, the pyramidalis, the gemelli, and the obtura- 
tores, being all inserted into the digital fossa of the great trochanter, 
act only on the upper fragment, while the gluteus medius and mini- 
mus, rotating the limb inward, act as much as ever upon the lower 
one. It is certainly true that in the three cases cited by Guthrie, 
M. Merrier and M. Michon, the foot was inverted; but in those of 
M. Nivet and of B. W. Smith, it was turned outward, notwithstanding 
the theory. 

(6.) The crepitation is sometimes very striking; at other times it 
is entirely wanting, in spite of all our efforts to elicit it ; such was 
the case in the subject of Fig. 68. R. W. Smith gives this difficulty 
of obtaining crepitation as a chief symptom of fractures with pene- 



558 A TREATISE ON FRACTURES. 

tration, forgetting that it has been as clearly pointed out in the 
intra-capsular variety. 

To these symptoms, admitted by all surgeons, others of more 
doubtful value have been added. Brunninghausen teaches that there 
is abnormal mobility of the great trochanter; Desault adds that it 
can be felt to turn on itself as on a pivot, when the thigh is rotated; 
and Bichat takes care to state that this sign is more perceptible 
when the fracture is at the base of the cervix. I have myself never 
met with it; I have been rather inclined to think, as I shall presently 
mention, that the trochanter described in the rotation of the bone a 
larger arc of a circle than it would when uninjured. 

R. W. Smith, again, thinks that an essential symptom of im- 
pacted fracture should be the difficulty of restoring the limb to its 
natural length. He has deduced this from the appearance of frac- 
tures of long standing, and in process of consolidation; but in a 
recent case the penetration will always yield to a tractile force of 
about forty pounds. The general law in regard to extension must 
also be borne in mind, that it is easy on the first day, but becomes 
difficult as soon as inflammation is set up in the muscles around the 
seat of injury. 

Lastly, M. Robert has pointed out the swelling of the greater tro- 
chanter, constant when the neck is driven in among the fragments of 
that process, but due to the engorgement of the soft parts when it is 
not broken. According to this, the symptom in question would be 
met with in a mere contusion of the hip. 

But there are other much more practical symptoms, furnished by 
the almost constant fracture of the trochanter, and by its various 
displacements. It is most generally tilted inward, as is seen in Figs. 
70 and 71; so that its external surface becomes superior, and its 
superior border internal. It seems then flattened and as it were 
crushed, and hence notably diminished in height. Thus its apprecia- 
ble height from base to summit varies from an inch and one-third to 
an inch and two-thirds in the femur of an old person; a comparison of 
Figs. 68 and 70 will show how much this is diminished in case of frac- 
ture. From this we see that if we measure the trochanter from base 
to summit, or even the whole femur from the condyle to the top of the 
trochanter, we find a notable degree of shortening on the side of the 
fracture; and that if we examine whether or not the trochanter is 
drawn up toward the crista ilii, a measurement from the base of the 
process will show that it is so, while one taken from its summit will 
present no great difference between the two sides. 

Besides this flattening, the trochanter sometimes undergoes an- 
other displacement backward, toward the sciatic notch, where it forms 
a prominence resembling the luxated head of the femur ; and when 
the foot is at the same time inverted, the differential diagnosis be- 
comes quite difficult. I have seen one example of this in the living 



A TREATISE ON FRACTURES. 559 

subject, and only perceived my error when a very manifest crepita- 
tion was elicited by my first attempts at reduction. I have observed 
a similar prominence, the foot being everted; and although the frac- 
ture was evident, I was at a loss to account for this phenomenon. 
Stanley alone, so far as I know, has clearly demonstrated by dissec- 
tion the nature of the lesion. He ascertained, in one case of frac- 
ture of ten days' standing, that it was a portion of the trochanter 
which had been thus thrown backward, only maintaining some con- 
nection with the shaft by means of the periosteum. In another 
case, the injury had occurred three years previously, and had always 
been doubtful in its nature ; it was the posterior and larger portion 
of the trochanter which had been carried backward, and which, in 
spite of its distance from the shaft, had at length become reunited 
to it.* 

The trochanteric fragment is sometimes also carried upward and 
forward ; Desault met with an instance of this, in which the broken 
piece was isolated, and could be moved in any direction, the shaft 
remaining at rest. 

And lastly, when this fragment is tilted inward, it pushes the up- 
per part of the neck in the same direction, (see Figs. 70 and 71 ;) 
and in spite of the penetration of the lower portion, it is certain 
that the distance of the head of the femur from the base of the tro- 
chanter is augmented ; that the trochanter thus makes a more consi- 
derable prominence outward than normally, and that it describes, 
when the thigh is rotated, a larger arc. I have made a comparative 
measurement, of the distance from the head to the trochanter in the 
case represented in Fig. 68 ; it was increased by one-third of an inch. 
This direct comparison I could not institute in the two other speci- 
mens; but the same space in a healthy femur amounted to ninety-one 
millimetres, [three and one-thirtieth inches;] now in the specimen 
from which Fig. 71 is taken, in which the head is somewhat flattened 
as the result of senile changes, it is ninety-seven millimetres, [three 
and one-quarter inches,] and in that represented in Fig. 70 it is as 
much as eleven centimetres, [three and two-thirds inches.] 

The course of these fractures is very simple ; bony union is in 
them the rule, its deficiency the exception. The callus forms, as in 
all fractures of the cancellous extremities of the bones, by the addi- 
tion of a little ossific matter on the outside, to fill up the angles or 
gaps left between the fragments, and by the complete fusion of the 
spongy texture within. Thus in Figs. 70 and 71, no other trace of 
callus is seen than the compact line showing the penetration of the 
lower portion of the cervix. The callus is also formed very rapidly, 
except in case of very great alteration of the bony structure. De- 
sault fixed forty days as the term required for consolidation ; in one 

* Stanley, Medico -Chir. Transactions, vol. xiii, p. 504. 



560 A TREATISE ON FRACTURES. 

instance he made an autopsy on a woman seventy-one years of age, 
at the forty-ninth day, and found a very firm callus. The subject of 
Fig. TO had worn no apparatus after the forty- eighth day; but as- 
suredly the union was not wanting in solidity. 

The consequences depend therefore solely on the amount of short- 
ening. In the patient mentioned, whose shortening really amounted 
to one inch, the halt was very marked ; extension and adduction 
were free, flexion was almost complete ; still, to equal these motions 
on the sound side, the pelvis moved a little on the last lumbar verte- 
bra; abduction alone was extremely limited. But in a man of 
seventy-four, who had by measurement no more than one-third of an 
inch shortening, the motions were almost perfectly restored in less 
than three months ; they evidently took place in the joint itself, and 
the patient could walk a league without a stick. The difference in 
the two cases, in regard to abduction, is readily explained by the 
different degrees of inclination of the head of the bone ; in Fig. 70, 
in which it is very much depressed, we see that upon the slightest 
attempt at motion outward, the neck of the femur would strike 
against the edge of the cotyloid cavity. But all cases do not termi- 
nate so successfully. Thus there has been seen, even when union 
had occurred between the fragments, an excessive formation of callus, 
more or less hindering the motions ; in Powell's case, two bony pro- 
longations sprang from the summits of the two trochanters, like but- 
tresses, bearing against the edges of the acetabulum. When consoli- 
dation does not occur, the deposition of bone is sometimes almost 
beyond conception; I have a preparation in which the upper extre- 
mity of the femur is buried, so to speak, in a mass of callus not less 
than twelve inches in circumference. M. Manzini has presented a 
very similar specimen to the Societe Medicate a" Emulation.* 

Lastly, extra-capsular fracture, like the other variety, may involve 
much more serious dangers ; too often, whether from the shock occa- 
sioned by the external violence, or from some unfortunate predispo- 
sition of the patient, there ensues nervous delirium, or intense fever 
of the adynamic type, which sooner or later terminates fatally. 
Sir A. Cooper even makes this a symptom peculiar to extra-capsular 
fractures, an idea which cannot be maintained, although they are 
perhaps somewhat more liable to its occurrence than the others. Of 
the eighteen extra-capsular fractures preserved in the Richmond 
Hospital Museum, nine proved fatal between the fifth and the fif- 
teenth day. 

This first danger being past, there may still ensue others, owing 
either to the patient's cachectic condition, or to some impropriety in 

* Manzini, Tlihse inaug., Paris, Aug. 16, 1841. M. Manzini gives at the end 
of his thesis a short description of my specimen, as well as of another, which I 
mentioned in connection with intra-capsular fractures, and which was given me 
by M. Teissier. 



A TREATISE ON FRACTURES. 561 

the treatment. The pain about the seat of the injury persists; cede- 
matous swelling of the affected limb, and sometimes even of the sound 
one, occurs ; a slow fever undermines the strength, impairs the appetite, 
and disturbs the sleep ; and in hospitals there appear occasionally also 
symptoms of scurvy. Sabatier says that he thus lost several patients 
by scorbutic wasting, at the infirmary of the Invalides ; the subject 
of Fig. 68 died at the end of three months, with the symptoms of 
scurvy very plainly developed. It is in these cases, in which the 
constitution is entirely broken, that sloughing occurs over the sa- • 
crum ; mere confinement could not bring it on. Upon dissection we 
find bloody or purulent effusions around the fracture, and in the 
joints ; sometimes chronic phlebitis, with obliteration of the venous 
trunks coming from the lower extremities ; and often the fracture is 
no more united than it was on the first day. Thus the fracture re- 
presented in Fig. 68, dating back more than three months, presents 
all the characters of a recent injury, except that the edges of the 
fragments are slightly worn. 

These consequences are common to all fractures of the cervix fe- 
moris. Wishing to ascertain the mortality from them in our large 
hospitals, I have consulted the tables obtained from the Hotel-Dieu. 

Of the 105 patients received, ten went out before the fifteenth 
day; these I have deducted. Of the remaining ninety-five, thirty, 
or nearly one-third, died. Fortunately, the dates of the deaths di- 
minish the fearfulness of this proportion. Thus : 

3 occurred on the same day as the accident ; 



4 


from the 4th to the 6th day after the accident ; 


2 


9th " 12th 


7 " 


21st " 37th 


5 


45th " 60th 


9 


70th " 187th 



The three deaths which occurred within the first twenty-four hours, 
were certainly independent of the fracture ; and we may likewise 
exclude, if I mistake not, many of those which were postponed till 
after the forty-fifth day. The mortality is still terrible ; but the line 
of treatment pursued had certainly a great deal to do with it, and 
for my own part, I have been far more fortunate. 

Has the age or sex of the patients any influence on the mortality? 
Among the women, there were fourteen deaths out of forty-nine 
fractures ; among the men, sixteen out of forty-six ; they were 
nearly equal in respect to the period of their occurrence after the 
receipt of the injury. As to the ages, we find : 

Under 50 years 11 fractures, 2 deaths. 

From 50 to 60 vears ... 
" 60 (O 70 u 
" 70 to 80 " 
" 80 to 90 " 

36 



38 


" 12 


27 


6 


4 


3 



562 A TREATISE ON FRACTURES. 

Thus below the age of fifty the danger is less; beyond eighty it 
becomes extreme. 13ut a very unexpected result, and one which 
needs to be verified by further research, is that the mortality is 
greater between fifty and sixty than between sixty and seventy, and 
especially than between seventy and eighty. 

The diagnosis presents serious difficulties. When there is no short- 
ening, eversion of the foot, or crepitation, it is hardly possible to dis- 
tinguish a fracture of the cervix from a mere contusion of the hip. 
.By forcibly turning the foot outward, as advised by M. Gerdy, we 
can doubtless lessen the obscurity of the diagnosis ; but by so doing 
we should risk the production of displacement, and the rupture of the 
fibrous tissues connecting the two fragments anteriorly; so that this 
means should be tried only with great caution. 

If the surgeon trusts to his eye as a test of the shortening, he will 
be liable to mistake for reality the apparent shortening which exists 
in the majority of lesions of the hip; and if crepitation be added to 
this, he may be in doubt between a double vertical fracture of the 
pelvis and a fracture of the acetabulum. Methodical measurement 
will show him in the first place whether the iliac spine has itself been 
carried upward, which besides crepitation is the only means of de- 
tecting double vertical fracture of the p.elvis; and fracture of the 
acetabulum only causes shortening when it is attended with disloca- 
tion, as will be mentioned hereafter. 

There are some extra-capsular fractures with displacement of the 
trochanteric fragment backward and rotation of the foot inward, 
which simulate luxation upward and outward. Here we must seek if 
possible to elicit crepitation; if this cannot be done, we must try to 
overcome the projection by means of strong tractions; or we may 
attempt to evert the foot, which luxation does not admit of, but which 
we can generally do in cases of fracture. 

Lastly, I have already alluded to a peculiar affection which has 
been more than once taken for fracture of the cervix femoris, even 
in examinations after death ; namely, rachitic degeneration [ramol- 
lissement] of the head and neck of the bone. Gulliver relates the 
case of a young soldier of nineteen, who having sustained a fall on 
his hip, continued to fulfil his duties for three years, and then began 
to limp ; he died eight months afterwards, and the autopsy revealed 
a flattening of the head of the femur, with shortening of the neck, 
in the centre of which was a bony induration.* This lesion is more 
common in advanced life, and it is therefore in old people that the 
error has been several times committed. Thus in each of the three 
cases reported by Langstaff, Chorley, and Field, and brought for- 
ward again by Amesbury, after a fall upon the trochanter the limb 
seemed shortened, rotated outward, impaired in its motions; the 

* Gazette Mtdicale, 1836, p. 842. 



A TREATISE ON FRACTURES. 563 

patients were treated for fracture of the neck of the bone ; at the 
end of a certain time they walked, but with more or less of a halt; 
on dissection several years afterwards, the cervix was found de- 
formed and shortened, and bony union was declared to have occurred. 
It is to be presumed that in all these cases the apparent shortening 
was mistaken for real, and the natural rotation of the foot for ever- 
sion from injury. We may therefore avoid such errors at the outset, 
by exactly measuring the shortening, and by ascertaining the degree 
of eversion with equal accuracy. Still, the diagnosis cannot be in 
this way placed beyond doubt except in a very recent case; and sub- 
sequently, when the disease has actually produced the lowering of 
the head and shortening of the neck of the femur, I know of no way 
of distinguishing it from an old fracture. 

It remains finally, the fracture being detected, to determine its 
seat, whether it be within the capsule or outside of it; and this is not 
the least difficult part of the differential diagnosis. 

Sir A. Cooper has attempted to solve the question by arguments 
drawn from the age of the patient, from the nature and severity of 
the fracturing cause, from the degree of pain, the amount of short- 
ening, etc. I have shown that several of these signs are absolutely 
worthless, and that in regard to others Sir Astley's views are contra- 
dicted by known facts. R. W. Smith and M. Robert have succeeded 
no better; and it is impossible, with the so-called signs given us by 
these three surgeons, to determine the exact seat of the fracture. I 
have in my turn attempted to compare, in the following table, the 
most prominent characters of the two lesions. 

Ixtra-Capsular Fractures. Extra-Capsular Fractures. 

(1.) Recent Cases. 

A fall on the foot or knee, abducted ; A direct blow, such as the kick of a 

a fall on the buttocks. horse, on the great trochanter. 

Slight swelling; no ecchyraosis. Marked ecchymosis about the hip. 

Pain about the insertion of the psoas Severe pain on pressure over the 

muscle, radiating sometimes even as far great trochanter, 
as the knee. 

Shortening sometimes absent at first, Shortening evident at once, perhaps 

suddenly coming on after several days increasing slightly in a few days, 
or even weeks. 

Shortening not over one inch. Shortening varying from one-third 

of an inch to two inches. 

Great trochanter intact, and ap- Great trochanter crushed at its sum- 

proaching the crista ilii by a distance mit, hence less elevated, and hardly ap- 

equal to the shortening. proximated to the crista ilii. 

Great trochanter apparently oblite- Great trochanter more prominent, 

rated. and describing a larger arc than that 

on the sound side. 

The femur of its normal length be- The femur seen to be shortened when 

tween the summit of the trochanter and measured from the external condyle to 

the external condyle. the summit of the great trochanter. 



564 A TEEATISE ON FRACTURES. 

Imra-Capsular Fractures. Extra-Capsular Fractures. 

( i reat trochanter never displaced, nor The trochanteric fragment sometimes 
abnormally movable. displaced backward or forward, some- 

times fixed, simulating the luxated 
head of the bone ; sometimes movable 
in every direction. 

(2.) Cases of Long Standing. 

Walking long difficult, and even im- Walking soon becoming firm and 

possible without assistance. steady. 

Shortening becoming greater, some- Shortening hardly augmented at all 

times even double its original amount, in some cases, and generally remaining 

always the same. 

Prominence of the trochanter appa- Prominence of the trochanter always 

rently increased, in reality diminished. more marked. 

Progressive wasting of the limb. Nutrition of the limb maintained. 

Voluntary motions taking place in Voluntary motions executed almost 

the lumbar region, but wanting in the entirely in the hip-joint, 
hip-joint. 

Among the symptoms enumerated in the above table, some furnish 
mere presumptions, while others afford certainty. Thus actual short- 
ening of the limb, joined with crushing of the trochanter, can only 
belong to extra-capsular fracture ; and the same is true of a shorten- 
ing of an inch and a half or two inches, coming on immediately. 
But to give things their true value, we must bear in mind that many 
fractures of the cervix afford no well-marked characteristics; that 
the swelling sometimes masks those which are most so, and that even 
the most methodical measurement does not remove all chances of 
error. In the case represented in Fig. 62, the real shortening was 
nine-tenths of an inch; but on several occasions during life I had 
made it out an inch and one-sixth. Our measurements indeed 
correct the illusion due to lateral inclination of the pelvis ; but some- 
times there is an inclination of it forward, constituting a new source 
of error, and one which is less easily avoided. Thus, while as a gene- 
ral rule measurement is worthy of our full confidence, it may occa- 
sionally give rise to inexact results; although the amount of error 
has never within my observation been more than one-third of an 
inch. The consequence is that we must not believe implicitly in any 
but marked differences ; with an inch and a third shortening, for in- 
stance, there is ground for suspecting the case to be one of extra- 
capsular fracture, but to complete the diagnosis other signs are ne- 
cessary ; while a shortening of an inch and a half or two inches would 
seem to me to be of itself a pathognomonic symptom. 

The gravity of the prognosis depends entirely on the complica- 
tions, and on the period of life; as for the fracture itself, we may 
generally promise a successful result, except as regards shortening, 
which is unavoidable. 

The treatment hitherto adopted in fractures judged to be suscepti- 
ble of consolidation, has been based mainly upon these three indica- 



A TREATISE ON FRACTURES. 565 

tions : (1) to correct the shortening ; (2) to obviate the eversion of 
the foot ; (3) to keep the fragments at rest. Sir A. Cooper has 
added another, — the pressing of the fragments together, so as to 
maintain their contact; M. Guyot, on the contrary, thinks it import- 
ant to protect them from any pressure whatever. All this calls for 
careful study. 

First Indication ; to correct the shortening. — This indication pre- 
sents itself so naturally, and its aim is so apparent, that most sur- 
geons have tried hard to fulfil it. But they have sought to do so by 
very different methods, which may be arranged under three principal 
heads. 

The first method is by permanent extension, made by means of 
loops, weights, splints more or less complicated, and even with actual 
machines. I have dwelt sufficiently on these forms of apparatus in 
speaking of fractures in general, (see ante, p. 196;) I have also stated 
the inconveniences attending their use. 

Struck with these disadvantages, Foubert thought to attain the 
same end by repeated extensions ; that is to say, the shortening being 
reproduced very soon after each time it was overcome, he renewed 
the tractions, at first daily or even every twelve hours, till the twelfth, 
fifteenth or twentieth day, and afterwards at longer intervals ; gene- 
rally abandoning it after the twenty-fifth day, and then merely keep- 
ing the limb confined with the ordinary lateral compresses.* 

Subsequently Brunninghausen, after making suitable extension, 
sought to keep it up by fastening the two limbs together. He used 
for this purpose a roller around the thighs above the knees, and a 
strong band of muslin to keep the feet together ; and lastly, a 
leather or wooden splint on the outer side of the thigh, fastened by 
straps to the pelvis and knees. Hagedorn devised a more ingenious 
apparatus on the same plan. He confined the sound limb by means 
of straps to a splint, reaching from the hip to the foot, having at its 
lower extremity, instead of a foot-piece, a wide board ; this was 
pierced with numerous holes for the attachment of bandages, by 
which both feet were to be immovably fixed to it. The pelvis was 
also confined to the splint by a broad band. Lastly, Dzondi modified 
this apparatus, chiefly by prolonging the splint up over the ribs, so 
as to fix the thorax to it with a strong strap. f 

Of these three methods there is one, — that of Foubert, — which is 
so foreign to all scientific ideas, that it can hardly be conceived of as 
having been seriously proposed. Such repeated extensions could 
have no other effect than to torment the patient, for the trifling satis- 
faction of lessening the apparent shortening ; and Sabatier, after 

* Sabatier, Me'rn. de VAcad. Roy ale de Chirurgie, tome iv, p. 644. 
t Brunninghausen, op. dt ; Hagedorn, Abhandl. uber den Bruch des Soften- 
ihalses, etc.. Leipzig, I -"- ; Dzondi, Bcitrage, etc., Halle, 1816. The two 
latter quotations are made from A. L. Richter. 



566 A TKEATISE ON FRACTURES. 

extolling this plan, at length admits that it cannot prevent the pa- 
tients from limping more or less, or from having the knee and foot 
turned somewhat outward; which is certainly evidence of its perfect 
uselessness. 

The fastening together of the two limhs has at least the advantage 
of insuring the immobility of the fragments ; but it is hardly con- 
ceivable that any one should expect to overcome real shortening by 
keeping the feet at the same level, without also firmly confining the 
pelvis, or consider the pelvis as thus confined merely by a transverse 
band or strap. 

There remains, then, permanent extension, properly so called. I 
shall say nothing of apparatuses constructed of bands, handkerchiefs, 
or loops of muslin ; one needs only to apply Desault's splint once, to 
be convinced that that celebrated surgeon was completely deceived 
both as to the value of his apparatus and the reality of his cures. 
In less than twenty-four hours all the bandages become relaxed, and 
if we tighten them up every day we are making repeated and not 
permanent extension. To combat successfully the constant contrac- 
tion of the muscles, there is needed a constantly acting force, which 
can only be obtained by strong leather straps, and a mechanical 
power greater than the hands of assistants ; of all the contrivances 
for this purpose, that which seems to me the best calculated to pro- 
duce the desired effect is the mechanical splint of Boyer, in which 
extension is made by means of a screw. But can even this restore 
the limb to its normal length ? I do not hesitate to affirm the con- 
trary. I have elsewhere given an account of the patient from whom 
the specimen represented in Fig. 70 was derived. He was a man 
fifty-four years of age ; he had been treated with all possible care by 
a justly celebrated surgeon, who had employed Boyer's apparatus. 
Extension was kept up steadily until the forty-eighth day, when it 
had to be abandoned on account of deep ulcerations about the ankle 
and groin. If we examine the callus, we see that the shortening 
could hardly have been more considerable if the limb had been left 
to itself. 

I may add that I have never seen, even in Boyer's own patients, 
the shortening overcome as stated by him ; and that, like Desault, 
he was deceived for the want of a sufficiently exact method of mea- 
surement. 

But I go still further ; I say that it would be dangerous, in the 
immense majority of cases, to make complete extension; and that 
prudence should forbid the surgeon's meddling with a shortening 
which is only moderate in its degree. 

After exposing, with due care, the fracture represented in Fig. 68, 
I tested the effect, in the dead body, of regular traction. The foot 
was drawn down by an assistant, another holding the pelvis back by 
means of a handkerchief folded cravatwise and passed between the 



A TREATISE ON FRACTURES. 567 

thighs, as in the contrivances of Desault, Boyer, and others. The 
results of the extension seemed to me at first very strange, although 
in fact, casting aside all preconceived ideas, they were quite simple. 
In the first place the angle between the cervix and shaft of the bone 
became inordinately widened, then the cervix was disengaged from 
the lower fragment, into which it had penetrated, and finally the tro- 
chanter was separated from the other two fragments ; so that the 
contact and the normal relations of the three were destroyed, and 
consolidation would have been utterly impossible. Let any one re- 
peat this experiment on a recent fracture, and I will answer for it he 
will never wish to try it in the living subject. 

Hence, except in case the shortening is extreme, unless for in- 
stance it exceeds an inch, it is useless and dangerous to try to com- 
bat it; and the only rational indication is to try to prevent its sub- 
sequent increase. 

Second Indication; to correct rotation outward. — We generally 
limit ourselves, in this respect, to bringing the foot nearly into its 
normal position, and in a very large number of cases this is sufficient ; 
but sometimes the fragments are not restored by this movement, as 
can be seen, first from the fact that the foot is not entirely vertical 
in its direction, and again from the hollow behind the trochanter not 
being re-established. Hence it happens that when the apparatus is 
left off, after consolidation has occurred, the foot falls out again more 
than it should, and its rotation inward is impossible. We should 
therefore insure reduction as follows : at the same time that we carry 
the foot inward, we should raise the trochanter and depress the mid- 
dle portion of the cervix, so as to restore the hollow alluded to. 

Retention may be accomplished by various means. . Sometimes the 
foot is attached to a sole, or to a board made fast in some way;, some- 
times the two feet are fastened together. M. Nelaton, admitting no 
other indication than this latter, makes his entire apparatus consist 
of two boards at right angles to one another, one being fixed by a 
bandage on the plantar face of both feet, while the other merely lies 
horizontally outward, so as to prevent any fresh deviation in this 
direction. 

Third Indication; to Iceep the fragments at rest. — It is easy to 
fix the lower fragment, but we have no purchase on the upper one, 
and can act r>n it only through the medium of the pelvis. In order, 
therefore, to fulfil this indication, we must confine both the pelvis 
and the lower extremity. 

Earle [Sir James] was the first who aimed to do this, semiflexing 
all the articulations by means of the triple inclined plane of his frac- 
ture-bed; and M. Bonnet, of Lyon.-, used for the same purpose his 
large cuirass, embracing the trunk and the limb in the extended po- 
sition. There is certainly no objection to either of these contrivances, 
except perhaps their complexity, and the difficulty of always obtain- 



568 A TREATISE ON FRACTURES. 

ing them. But if their utility is demonstrated, their necessity is not; 
and this is enough to exclude them forever from ordinary practice. 

Other surgeons, going to the opposite extreme, and pushing sim- 
plicity to excess, have almost abandoned the limb to itself. Thus 
Dupuytren arranged under the ham a sufficient number of pillows to 
keep the thigh nearly at a right angle with the trunk, and the leg 
nearly at a right angle with the thigh ; the thigh and leg being kept 
in place merely by two cloths folded cravatwise, passed across over 
them, and tied to the frame of the bed on each side. M. Nelaton 
prefers the extended position ; but as has been stated, he lets the 
limb lie upon the bed, with no other apparatus than the foot-piece to 
hinder rotation outward. Doubtless, satisfactory results have been 
obtained in cases so treated, but more by chance than by prudent 
attention; and Dupuytren's apparatus, for example, is perhaps the 
one most favorable to shortening and deviation of the limb. 

The juste milieu, which seems to me far preferable, is attained by 
those who first fix the lower extremity firmly, and then seek to give 
the pelvis such stability that the process of consolidation may not 
be hindered. Contrivances for making permanent extension ; fas- 
tening the injured limb to the sound one; compresses or ordinary 
splints, extended along the entire limb; immovable apparatuses, 
have been by turns made use of, and lastly the double inclined plane. 
I find in this latter the double advantage of relaxing the joints and 
leaving the limb exposed in its whole length; it is therefore the one 
which I employ in preference. 

[In the United States, the extended position is the one which finds 
most favor, in all cases of extra-capsular fracture of the femur ; the 
mode of treatment will be mentioned in connection with § Y, on 
fractures of the middle third of the bone.] 

Fourth Indication ; to press the fragments against one another, 
— Sir. A. Cooper recommends for this purpose a wide leather band 
buckled around the pelvis, embracing and pressing upon the great 
trochanter. But I must say I have found no advantage from this 
plan, while it seems to me to involve numerous inconveniences. 

If the trochanter is already inclined inward, pressure can only tilt 
it farther over; if it has not yet undergone any displacement, pres- 
sure would be the surest means of causing it. As to the fracture of 
the cervix itself, either it is extra-capsular, and the inner fragment, 
being driven into the substance of the outer one, needs no external 
pressure ; or it is intra-capsular, and the pressure already exerted 
by the muscles is only too great, since the inner fragment is seen to 
waste away beneath it. Thus this indication is in every way want- 
ing in foundation. 

M. Guyot, reasoning on the contrary from this wasting of the 
inner fragment, proposed to combat the muscular action, and to keep 
the trochanter outward; with this view he advised putting a pad 



A TREATISE ON FRACTURES. 569 

between the thighs, on a level with their lower half, and approxi- 
mating the two knees by means of a few turns of a bandage.* But 
without examining into the possibility of obtaining the desired result 
in this way, I do not see what we have to expect from it in intra- 
capsular fracture; and in the extra-capsular variety the trochanter 
is already too much carried outward, and needs no further displace- 
ment. 

On the whole, therefore, to correct the eversion of the foot, to 
give the fragments the necessary degree of immobility, and to pre- 
vent any increase of the shortening, or even to try to diminish it if 
it is excessive, must constitute the whole aim of the surgeon. For 
my own part, I begin by putting the patient on a quite horizontal 
surface, in order that the weight of the trunk may not push down 
the pelvis toward the thigh; and with this same object I put also a 
wide board underneath the mattress, and allow the head to rest only 
on a bolster or a single pillow. The limb is then placed upon the 
double inclined plane, which is previously padded; the foot, care- 
fully brought into the vertical position, is fastened to the foot-piece; 
the pelvis, sliding back by its own weight upon the upper plane, 
makes continual extension, but gently, without pain or effort, and 
the thigh is confined to the apparatus by a handkerchief folded cra- 
vatwise. This will suffice in ordinaivy cases, if the patient is tract- 
able; but we may if necessary apply another cravat over the leg, 
and fasten the pelvis itself by a long sheet, folded, and tied across 
the bed. Lastly, if the shortening is so great as to require atten- 
tion, we may arrange another folded sheet so as to draw the axilla 
up toward the head of the bed, the foot being held down by the foot- 
piece. 

It is not necessary, unless in exceptional cases, to keep the limb 
in the apparatus for more than forty -five or fifty days; on the one 
hand, from what has been already stated, any longer retention of it 
would be useless; on the other, I have elsewheref shown the serious 
consequences of too prolonged confinement, to which cause I mainly 
ascribe the enormous mortality at the Hotel-Dieu. I would not ad- 
vise that the patient should be at once allowed to get up ; the weight 
of the body, or even of the limb, is too great for a callus so recently 
formed. But he may move about in bed, so as to somewhat restore 
the suppleness of the joints; eight or ten days afterwards he can 
begin to use crutches, and I have more than once seen a patient in 
a condition to walk by the seventieth day. 

Treatment thus directed has the advantage of answering equally 
well for fractures within or without the capsule, the differential diag- 
nosis being rendered indispensable only in regard to the prognosis. 

* Gazette Medicate, 1835, p. 692. 

t Malgaigne. De quelques dangers du trait, ordin. desfr. du col du femur; 
Bulletin de Therapeutique, Aug,, 1841. 



570 A TREATISE ON FRACTURES. 

Lastly, in those still more doubtful cases, in which we do not know 
whether there is a fracture or a mere contusion, it is always the best 
course for us to follow ; and by rest on the double inclined plane I 
have even succeeded in dissipating coxalgic symptoms, traumatic or 
otherwise, when in an early stage. 



§ III. — Fractures of the G-reat Trochanter. 

Fracture of the great trochanter by itself, without injury of the 
cervix femoris, is an extremely rare lesion. Desault and Boyer 
have spoken of it, but without citing any instances; Sir Astley 
Cooper has devoted a special article to it, but he confounds it with 
that variety of fracture of the neck of the bone in which the process 
in question forms part of the superior fragment. Hitherto, there- 
fore, nothing has been more obscure than its history. 

It presents several varieties. Thus the process may be broken, 
without any rupture of the fibrous tissues covering it; and then the 
diagnosis is almost impossible; such a case was communicated to Sir 
A. Cooper by Aston Key, the fracture being only recognised by dis- 
section. Again, the fibrous .tissues being divided, the trochanteric 
fragment is left to the action <*f the muscles, which draw it upward 
and backward, or in some exceptional instances forward; Hargrave 
found a fracture of long standing in the body of an old woman, in 
which the trochanter had been drawn upward and backward to a dis- 
tance of an inch and three-quarters from the other fragment. Lastly, 
the trochanter is sometimes crushed and splintered; Clarke gives a 
case of this kind.* 

This fracture does not seem, like the preceding ones, to affect old 
persons in preference; Aston Key's patient was a girl of eighteen, 
and Clarke's a man of thirty-two. 

In every case of this injury hitherto published, the cause was a 
violent fall on the hip. It may however be presumed that a direct 
blow upon the process would be quite as capable of giving rise to it. 

The symptoms vary according to the character of the injury in 
each instance. In Aston Key's case there was neither contusion 
nor swelling; the girl got up after her fall and returned to the house, 
but with much pain and difficulty ; in a word, there was nothing 
to indicate fracture. 

In Clarke's case, the hip was the seat of some contusion, and 
of very considerable swelling; there was quite severe local pain, 
which however was only slightly increased by pressure; by raising 
the foot, or rotating it inward, the patient was forced to cry out; 

* Hargrave, Gaz. des Hopitaux, March 22, 1842 ; Clarke, American Journal 
of the Med. Sciences, Nov., 1836, p. 181. 



A TREATISE ON FRACTURES. 571 

crepitation -was entirely wanting. Hargrave, having only discovered 
his fracture upon the dead body, says merely that before the dissec- 
tion there was nothing abnormal in the appearance of the limb. 

We can readily see how this fracture, even with the most marked 
displacement, would influence only slightly the functions of the limb, 
unless by causing pain; and that there are muscles enough still at- 
tached to effect rotation inward or outward, although with some dif- 
ficulty. The local pain and the contusion are indications of but 
small value, and to establish the diagnosis, displacement or crepita- 
tion must be made out. Two instances, one given by Mr. Bransby 
Cooper and the other by Sir Astley, will show at once the difficulty 
and the mode of overcoming it. 

Mr. Bransby Cooper had already made two careful examinations 
of his patient, without any result. He conceived the idea of making 
him stand up ; in this position the buttock presented a sort of knotty 
prominence, apparently constituted by the retracted muscles. The 
trochanter could not be felt, either at its normal place or anywhere 
else. The patient was laid upon his backhand the thigh forcibly ad- 
ducted, while pressure was made over the glutei muscles as if to 
bring clown the detached fragment, when crepitation was distinctly 
perceived.* 

In the other instance, a man fifty-one years old had had a severe 
fall upon the great trochanter. At first he perceived only the pain 
and swelling inseparable from a violent contusion, but these were 
more than usually persistent; on the twenty-fifth day, in moving the 
limb, one of the surgeons heard crepitation, and drew the attention 
of another to it. Brodie, being called in, sought for this crepitus at 
first in vain; but at length he succeeded in eliciting it by making 
extended movements of rotation, and concluded that the fracture 
was in the neck of the bone. Sir A. Cooper was in his turn con- 
sulted at about the fiftieth day, and putting his hand beneath the 
trochanter, easily raised it into its natural position; when every one 
agreed that the fracture occupied the great trochanter just at its 
junction with the rest of the hone. Mr. Harris, who describes the 
case, considers that at the time of this last examination the frag- 
ments were separated by two inches, and thinks that they became so 
after Brodie's first visit. This circumstance shows unmistakably 
that the case was one of fracture of the great trochanter merely, 
since with such an amount of separation there was still no loss of 
length in the limb.f 

Thus the local pain, increased by movements which tend to sepa- 
rate the fragments, such as flexion of the thigh, or its rotation in- 

* UE . tome i, p. 505. 

t The report of this case has been completely mutilated in the translating into 
French, and should be read in the original. [I have been unable to find the ac- 
count in any English work, or I should have transferred it to this note.] 



572 A TREATISE ON FRACTURES. 

ward; the hindrance of these movements; the crepitation, obtained 
either by strong rotation, by forcible abduction, or perhaps by a com- 
bination of these two manoeuvres; and lastly, the examination of the 
trochanter, which is found to be flattened or deprived of its summit, 
with the displacement and mobility of the detached portion; these 
are the data upon which may be founded a positive diagnosis. 

I pass over some other symptoms mentioned by Sir Astley Cooper, 
such as the eversion of the foot and the shortening of the limb; 
they are of impossible occurrence, and only enter into his descrip- 
tion from the fact that he has, as I have stated, confounded two essen- 
tially different fractures. 

The prognosis is not at all serious when the separation is but slight. 
Mr. Bransby Cooper states that he obtained a perfect cure in his 
patient. But a considerable interspace existing between the frag- 
ments would hardly permit us to hope for their reunion; it has been 
seen to be persistent in Hargrave's case; while in that of Sir A. 
Cooper, after a confinement in bed for over five months, it is stated 
that great thickening was observed in the parts around the trochanter, 
and that the hip-joint entirely recovered its functions; but no refer- 
ence is made to consolidation, which therefore remains at least very- 
doubtful. 

The treatment should, in my opinion, consist merely in keeping 
the limb abducted and rotated outward, with the knee slightly flexed, 
so as to make the position more comfortable. At the end of forty 
days motion may be allowed in the limb ; for by this time union 
either will have occurred, or very probably never will occur at all. 
Mr. B. Cooper put the limb in abduction, and sought to keep up co- 
aptation by means of a bandage; but any bandage would here be 
not only useless, inasmuch as it could not counteract the muscles of 
the buttock, but injurious by endangering the still further depression 
of the trochanteric fragment. Hence I shall not describe the very 
complicated apparatus employed by Sir A. Cooper; suffice it to say 
that the patient, thus kept in bed for more than five months, could 
not bend the knee for two months more, and only regained the use 
of this joint by dint of great perseverance. 



§ IV. — Fractures just below the Trochanters. 

I give this name, following the example of Sir Astley Cooper, to 
fractures affecting the femur either immediately below the lesser tro- 
chanter, or an inch or two farther down; that is to say, within the 
upper third of the entire length of the bone. 

They would appear not to have been specially pointed out before 
the time of Fabricius Hildanus, who gives a remarkable instance in 
point, and who merely says further that it is more difficult to obtain 



A TREATISE ON FRACTURES. 573 

union ■without deformity in them than in fractures occurring lower 
down.* Boyer acknowledges this difficulty, and accounts for it by 
the fact that nothing hinders the upper fragment from riding for- 
ward. Sir A. Cooper carries the idea further; he asserts that the 
upper fragment is drawn upward and forward by iliacus and psoas, 
till it forms a right angle with the trunk ; giving in illustration a 
drawing of a fracture of the kind, preserved in the museum of St. 
Thomas's Hospital. Now all this is more or less inaccurate, and the 
history of this fracture needs to be stated almost entirely anew. 

It must be stated first that it is quite as common as other frac- 
tures of the diaphysis. Of twenty-eight fractures of the shaft of 
the bone, observed during life, I found ten seated in its upper third; 
and there are seventeen similar preparations in the Muse'e Du- 
puvtren. 

This fracture presents several varieties, according as it is single 
or multiple, or at a greater or less distance from the trochanters. 
Fig. 72 represents a fracture seated almost immediately below the 
trochanter minor; the lower fragment has ridden up very much pos- 
teriorly, and an enormous bony stalactite embraces the under part 
of the head and neck of the bone. In Fig. 73 the injury has taken 
place a little lower down; the upper fragment is so turned outward 
as to leave the other by more than one-third of an inch, and the 
callus must have filled up the interval thus left. Fig. 74 shows a 
double fracture in the upper third of the shaft. 

When the fracture is very close to the lesser trochanter, it is quite 
often comminuted, and combined with extra-capsular fracture of the 
cervix. A little lower down, it sometimes assumes a serrated form, 
especially in young subjects; but it is much more commonly found 
running obliquely. At least eleven of the seventeen specimens in 
the Musee Dupuytren are of this last variety. This obliquity is ex- 
tremely variable, and may affect any direction whatever; but the 
one most generally seen is downward and inward, as in the upper 
fragment in Fig. 74. 

This frequency of oblique fractures is dependent on the nature of 
the determining causes. It is truly remarkable how few of these 
are direct. Of my ten cases, no less than eight were indirect, arising 
from falls on the feet, missteps, etc. It is upon this portion of the 
femur that muscular action seems also to act in preference, when it 
is sufficiently powerful to break the bone. PoupeVDesportes relates 
that a little negro twelve or thirteen years old, being attacked with 
tetanus, had such violent convulsive movements of his lower limbs 
that the feet were turned heel-foremost, and that both femurs were 
broken at their necks, the fragments protruding at the outer side of 
the thighs. Beauchene has given an account of a man thirty-four 

* Fabricii Hildani, Cent, v, Obs. 86. 



574 A TREATISE ON FRACTURES. 

years of age, who while sliding on the ice felt himself in danger of 
falling backward, and made a violent effort to keep up; he did not 
fall, but he heard at the instant a crack high up in the right thigh, 
which was found to be broken below the trochanters.* 

The symptoms are in the first place, as in all fractures of long 
bones, pain, swelling, loss of power in the limb, preternatural mo- 
bility at the seat of injury, and crepitation, in general readily per- 
ceived. But the displacements call for special study. 

Sometimes the fragments remain interlocked, and no overlapping 
is possible ; but even then it is excessively rare for the bone to main- 
tain its natural direction ; the upper fragment is more or less strongly 
abducted, so as to form with another an obtuse angle salient out- 
wardly. Of this a remarkable instance is afforded in No. 162 in the 
Muse'e Dupuytren. By reason of this abduction, the trochanter is 
placed on a much higher level than the head of the femur; in other 
words, the latter is strongly inclined downward and inward, and 
hence results a shortening so marked that we cannot sivfficiently 
wonder that it has attracted so little attention among surgeons. 

It is true that when the fragments become disengaged from one 
another there is necessarily overlapping, and always to a consider- 
able extent; but even then the shortening arising from the angular 
deformity is as great, or indeed greater, than that caused by the 
overlapping. 

Thus in the specimen from which Fig. 72 is taken, the overlapping 
being one inch, the whole amount of shortening is two inches. In 
that of Fig. 73, the overlapping is not more than one-third of an 
inch; the total shortening is an inch or more. Lastly, the double 
fracture shown in Fig. 74, with its double overlapping, would have 
given but an inch of shortening, which is, however, increased to two 
inches or more. But these are only the simplest cases; in Fig. 73, 
for example, the angle is at least 140° ; but if the fracture were left 
to itself it would lessen to 120°, 100°, or even less. No. 122 in 
the Musee Dupuytren presents a fracture of the upper third of the 
femur, with very slight overlapping, and the fragments at an angle 
of about 85° ; the shortening is more than five inches. 

To what cause must we ascribe this displacement, so constant and 
so marked? At the time of my first observations, it seemed to me 
as though the patient had felt an itching at the inner side of the 
thigh, and putting the hand to the spot, had pulled the fragments 
outward. Afterwards, having met with several cases in which such 
an explanation was inadmissible, I blamed the inner splint and its 
padding, which by their tendency to push apart the upper portion of 
the thighs would tend also to push outward the two fragments. The 

* Poupee-Desportes, Hist, des Mai. de Saint Domingue, p. 171 ; Beauchene, 
Journ. de M6d. de Leroux, tome xxx, p. 336. 



A TREATISE OX FRACTURES. 575 

pressure of the counter-extending band in the groin may perhaps 
also aid in this result when permanent extension is employed. Sub- 
sequently, having seen the same angle formed under the use of other 
apparatuses, I observed that the patient's pelvis sunk into the mat- 
tress, thus drawing the head of the femur inward, and leaving the 
other end of the upper fragment to stick outward. Doubtless each 
one of these causes has its share in the effect, and it is well that they 
should be pointed out, that the surgeon may be aware of them, and 
guard against them as much as possible. But they do not account 
either for the constancy of the displacement or for its occasional ex- 
tent. I think then at present that muscular action should be looked 
upon as the main source of this; the powerful muscles at the inner 
side of the thigh represent the chord of the arc formed by the neck 
and shaft of the femur ; when this arc is broken, the muscles act by 
approximating its extremities, meeting with no resistance; on the 
contrary their action is rather aided by the muscles inserted into the 
great trochanter, which favor that motion of abduction by which the 
upper fragment is carried outward, while the lesser secondary causes 
before alluded to go to increase the general effect. 

The angular displacement is therefore the principal phenomenon of 
these fractures. But what shall we say of the displacement forward 
described by Boyer and Sir A. Cooper? I must say here that I have 
never met with it in the degree indicated by them; most generally it 
is combined with that already discussed, and even then the upper 
fragment makes a prominence forward of not more than one to two- 
thirds of an inch. The drawing given by Sir Astley represents a 
fracture analogous to that in Fig. 73; the real displacement is out- 
ward ; and he was deceived by the circumstance of the lower frag- 
ment being involved in the eversion of the foot, whence its anterior 
surface is brought into relation with the most prominent part of the 
upper fragment. Upon the living subject such an error could never 
be possible; and even in dried preparations, it suffices to remark 
that it is always the outer and not the anterior face of the bone which 
looks upward, to prove that the displacement is in the direction of 
abduction. 

But this is not all. Not only then is the projection of the upper 
fragment forward reduced to something very slight, when it does 
exist, but in a good many cases it is wanting. Of the seventeen 
specimens in the Muse'e Dupuytren, there are seven, a very large 
proportion, in which it is not present. In three of these the frag- 
ments, being interlocked, have undergone only angular displacement; 
in four, the fracture being oblique downward and backward, the lower 
fragment rides up forward. I have given in my Anatomic Ghirur- 
gicale the history of a fracture just below the trochanters in a child 
of seven, with a marked prominence forward of the lower fragment. 
The specimen represented in Fig. 72 presents a singular peculiarity, 



576 A TREATISE ON FRACTURES. 

which could not be rendered in a drawing ; the upper fragment rides 
in front of the lower ; and yet, so far from obeying the muscles which 
should draw it forward, it is slightly inclined backward, as if to give 
the most formal contradiction to the theory. 

There are besides these several other varieties in the relative posi- 
tions of the two fragments ; the lower one is very often inside, some- 
times outside of the other, principally according to the direction of 
the fracture. The only displacement of this fragment which calls 
for special attention is its rotation outward, due to the eversion of 
the foot. 

The course of these fractures presents nothing peculiar; they 
unite as well and as rapidly as those about the middle of the bone; 
when they are very close to the trochanter the callus is sometimes 
exuberant, as in Fig. 72 ; but most commonly it is regularly formed. 
"When the two fragments are joined at a very marked angle, besides 
the limping inevitably caused, the limb is left somewhat feeble; I 
have elsewhere (p. 264) alluded to a case of fracture of this kind, 
which after an interval of six or seven years was reproduced by a 
very trifling fall. 

The diagnosis is a matter of little difficulty when the fracture is 
simple, recent, and at some distance from the trochanters. If it is 
multiple in form, and very close to the lesser trochanter, and if the 
lower fragment is strongly drawn up behind the other, as in Fig. 72, 
it will almost certainly be confounded with extra-capsular fracture. 
The surest evidence in such a case would be derived from the mo- 
bility of the lower fragment while the great trochanter is firmly 
held; and most commonly the angle salient outward will give the 
surgeon a clue. 

The prognosis is quite favorable when the fragments are inter- 
locked; when on the contrary they overlap one another, we must 
consider shortening as almost inevitable. Sir A. Cooper seems par- 
ticularly apprehensive of imperfection in the callus. Facts, however, 
show that false joint is not more commonly met with in the upper 
than in the lower portion of the femur. Of thirteen cases collected 
by Norris, seven were situated high up, six lower down ; of eight cited 
by M. Gueretin, three only were in the upper part of the bone.* 

The treatment should vary according to the relations of the frag- 
ments. If they remain interlocked, which is a favorable circum- 
stance, the chief indication is either to prevent or to correct any 
angular displacement. When this already exists, it may easily be cor- 
rected by causing moderate traction to be made on the pelvis and foot 
in opposite directions, and pressing with both thumbs upon the salient 
angle until it disappears. But to maintain the reduction so made is 

* Norris, op. cit.; American Journal of the Med. Sciences, 1842 ; Gu6r6tin, 
Presse Mtdicale, p. 45. 



A TREATISE ON FRACTURES. 577 

more difficult; permanent extension, when the point oVappui is taken 
in the groin, endangers the further displacement of the fragments, 
and none of the other modern forms of apparatus satisfy the indica- 
tion ; surgeons have in met overlooked it. The plan by which I have 
been most successful is as follows: 

I cause the patient to be laid upon a flat bed, with a wide board 
beneath the mattress, the head moderately raised, the two lower ex- 
tremities extended and parallel. The knees and feet are bound 
together with two handkerchiefs folded cravatwise. I then place on 
the outer side of the broken thigh a wide splint, which should reach 
beyond the crista ilii above, and as far as the calf of the leg below. 
A pad, much shorter than this, is put between the splint and the 
thigh; the upper end of the splint is then drawn toward the crista 
ilii by means of a handkerchief or a strip of lead-plaster, or still 
better by a girdle buckled around the pelvis, and its lower end 
toward the limb by two bands of the same kind, one above and 
one below the knee. This splint, tightly applied, exerts at the 
seat of fracture a pressure well calculated to prevent the forma- 
tion of an angle between the fragments; but it must not be im- 
agined that the putting on of such an apparatus will do every- 
thing. In the first place, it is likely to become relaxed, and must 
be daily examined to insure its remaining firm; besides which we 
must guard against the unfavorable conditions alluded to, warning 
the patient of their probability, and if he is intractable, fastening the 
trunk securely by means of folded sheets; in a word, we must watch 
him unceasingly ; and even with all this, success is very difficult to 
attain. 

Overlapping involves another indication still more difficult of ful- 
filment. Slight permanent extension is then necessary, either to 
prevent any increase of the overlapping, or to diminish it as much as 
possible. If the upper fragment does not make a marked projection 
forward, I should still prefer the extended position, making extension 
as usual by the foot, and counter-extension by loops passed beneath 
the axillae. In the contrary case I should place the injured limb by 
itself on a double inclined plane, the flexion however being very slight 
in degree. In fact, the more the knee is bent, the harder it is to fix 
the outside splint intended to counteract the angular displacement; 
which I regard as the great point in all these cases. When the limb 
is isolated, whether in the flexed or extended position, it is important 
to in-ure the position and the immobility of the foot, so as to pre- 
vent its eversion and the consequent rotation outward of the lower 
fragment. 

Sir Astley Cooper has recommended quite a different position : he 
would have the knee well raised on a double inclined plane, and the 
trunk at the same time supported by cushions at an angle of forty- 
five degrees, so that the patient would be nearly sitting up. His 

37 



578 A TREATISE ON FRACTURES. 

aim was to suit the other parts to the position of the upper frag- 
ment, which he believed to be strongly raised up forward. I have 
shown what this pretended displacement amounts to; the indication 
is purely imaginary. 

Lastly, if either of the fragments should make in either direction 
a prominence requiring to be corrected, this may be done as nearly 
as possible by means of small splints placed almost directly upon the 
projecting points and fastened by strips of lead-plaster. 

If the outside splint seems insufficient, we may substitute for it the 
wrought-iron trough of Fabricius Hildanus, or the hollow wooden 
splint elsewhere described. (See p. 268.) 

The apparatus may be removed by the fortieth day in children, by 
the fiftieth or sixtieth in adults ; but it is prudent to make the patient 
move his limb in bed for about ten days before giving him crutches, 
and to make him keep to the crutches until we are well assured that 
consolidation has duly taken place. 



§ V. — Fractures in the Middle Third of the Femur. 

It is to these fractures that nearly all that has been written con- 
cerning fractures of the shaft of this bone properly belongs. If I 
may judge however from my limited number of observations, they 
are not more common than the preceding variety, since they consti- 
tute only eight in my total of twenty-eight cases. 

They may be single, multiple, or comminuted. If single, they are 
serrated or oblique; Figs. 76 and 77 show a fracture with wide in- 
dentations, the two portions firmly interlocked; Fig. 75 represents 
one running obliquely from above downward and from behind for- 
ward. It is quite remarkable, but this obliquity downward and 
forward has seemed to me to occur most commonly in these cases, 
while in the upper third the obliquity is generally downward and 
inward. 

Multiple fractures are more common in the middle third of the 
femur than at either of its extremities. They are generally double, 
or in other words, the shaft is divided into three principal fragments ; 
but the middle one of these rarely comprehends the entire thickness 
of the bone, being rather a large splinter embracing half or more of 
it, and ordinarily detached posteriorly; sometimes belonging to both 
the others, which are then both bevelled off like the reed of a cla- 
rionet [en bee de flute] ; sometimes to only one, and then rather to 
the inferior, which alone is bevelled off obliquely at the expense of 
its posterior face. When the middle fragment does involve the whole 
thickness of the bone, one of the fractures generally is seated in the 
middle third, and the other in the upper. In the Muse'e Dupuytren 



A TREATISE ON FRACTURES. 579 

there is one specimen of triple fracture, which is the only one I 
know of. 

Oblique fracture is less common here than in the upper third, and 
there is likewise a marked difference in the nature of the deter- 
mining causes. Thus of my eight cases five were produced directly, 
three indirectly. I have been unable to find any authentic accounts 
of fractures of the middle third of the femur due to muscular action. 

I shall merely mention the symptoms which are common to this 
and to all other fractures : pain, loss of power, mobility, crepitation, 
etc. The study of the displacements is of more importance. 

There are in the first place some serrated fractures in which the 
fragments remain in contact; this fortunate circumstance is observed 
mainly in children and rachitic persons, but I have seen several in- 
stances of it in healthy adults. The fracture then presents itself 
under three conditions. Sometimes the periosteum is unbroken, and 
there is no crepitation ; the only possible displacement is an angular 
one, which is quite often wanting, and the injury is recognised by 
this single sign, — the facility of bending one fragment upon the other. 
Sometimes again the periosteum may share in the rupture ; the frag- 
ments may still be end to end, although the serrations may be changed 
in their relative positions ; besides mobility and angular displace- 
ment, some crepitation may be perceived. Figs. 76 and 77 present 
a curious example of this variety. Lastly, the two fragments may 
undergo a lateral displacement in nearly their whole thickness, and 
yet remain nearly end to end, by reason of the entanglement of the 
fractured surfaces to a greater or less extent; thus in Fig. 75, the 
fracture being slightly oblique downward and forward, the upper 
fragment is seen to be carried in front of the lower, and yet caught 
by its posterior wall against the anterior wall of the latter. There 
was in this case slight overlapping, the two walls in contact having 
been broken at different heights; there was also a projection of the 
upper fragment forward and of the lower one backward; still, this 
partial entanglement of the two fragments had the effect of greatly 
reducing the overlapping. 

When, finally, the fragments are entirely disengaged from one 
another, there is an overlapping more or less considerable. The 
upper fragment then almost always passes in front of the other; it is 
somewhat displaced thus in Figs. 75, 76, and 77 ; and of fourteen 
single fractures of the middle third of the femur, in the Muse'e Du- 
puytren, it has gone in front in twelve, behind in only one ; in the 
remaining case there was no separation. This is the more remark- 
able, inasmuch as we see nothing like such constancy in fractures in 
the upper third. I had at first conceived it to be due to the peculiar 
obliquity of fractures in the middle portion, but as serrated fractures 
present the same phenomena, its cause must evidently be sought 
elsewhere. 



580 A TREATISE ON FRACTURES. 

With the overlapping and displacement in the direction of the 
thickness is almost constantly combined angular displacement, the 
angle generally being salient outward. I have several times seen it 
directed outward and forward, and once almost entirely forward ; in 
the Muse'e Dupuytren there is a specimen (No. 123) in which the 
angle should tend to elevate the head of the bone, and to elongate 
rather than to shorten the limb ; but when it is forward, and espe- 
cially when it is outward, it becomes a very efficient cause of short- 
ening. The angle is indeed generally less acute, and gives rise to 
less shortening when in the middle third than when in the upper; 
although this may, in fractures of the former kind which are not 
properly attended to, attain nearly the same degree ; No. 131 in the 
Musee- Dupuytren presents an angle of 110° to 115°. 

Lastly, there is one source of displacement which affects only the 
lower fragment, — rotation outward arising from eversion of the foot. 
It may happen here, as in fractures of the neck of the bone, that the 
rotation takes place inward, the foot being turned in this direction; 
an instance of this exists in the Mus£e Dupuytren. 

These fractures, when simple and without displacement, unite in 
forty or fifty days ; sometimes they require two or three months, 
when the fragments overlap one another, being in contact only by 
their lateral surfaces. When the two ends cannot be made to oppose 
one another, so as themselves to counteract the muscular contrac- 
tions, it is impossible to preserve the normal length of the limb, 
whatever may be the apparatus or method employed. There has 
been too much discrepancy of opinion among surgeons in regard to 
this. Hippocrates gives the idea that the shortening can always be 
obviated; Celsus goes to the opposite extreme, declaring that a thigh 
once broken must ever remain shorter than its fellow. At a period 
by no means remote from our own, Desault claimed to cure all frac- 
tures without shortening, and his journal contains several such cases. 
In imitation of him, many surgeons have varied, corrected, and im- 
proved apparatuses for permanent extension, and have announced as 
complete successes from them. I must however state positively that 
I have never obtained anything of the kind, either with contrivances 
of my own, or with those of others, or even when I have invited the 
inventors of such apparatuses to apply them in my wards. I have 
more than once examined persons said to be cured without any short- 
ening, but always discovered such shortening by careful measure- 
ment. The mistake of all those who have thought they had obtained 
these miraculous cures, was that they never dreamed of comparing 
the two limbs in regard to their length; I will say, moreover, that 
they were most commonly ignorant of the proper way to obtain a 
good and correct measurement. Some have been deceived in another 
way ; they have lighted upon fractures with interlocking, especially 
in young subjects, and have imagined that they had corrected by 



A TREATISE ON FRACTURES. 581 

treatment a shortening which never existed. In short, when the 
fragments remain in contact, or when we can replace them and keep 
them so by means of their serrations, it is easy to cure a fracture of 
the femur without shortening; in the absence of these two conditions 
the thing is simply impossible. 

Several distinguished surgeons of the present day, recognising this 
impossibility, have abandoned the idea of permanent extension. 
They allege moreover that an overlapping of even as much as an 
inch is of slight consequence, and involves no limping. I cannot 
entertain this view. I have seen persons walk very well with one- 
third of an inch shortening, but with more than this they either limp, 
or must wear a thick-soled shoe ; or possibly their halt is masked by 
a lateral inclination of the spine. Hence we see how grave a frac- 
ture with overlapping must always be, and what caution we should 
observe in giving a prognosis. 

The diagnosis is very simple as regards the mere solution of con- 
tinuity. The difficulty in the great majority of cases lies in the dif- 
ferential diagnosis between the serrated, oblique, multiple and com- 
minuted varieties ; we may generally suspect an oblique fracture 
after indirect violence, a serrated one after direct ; but we have no 
certainty in regard to this except when the fragments remain inter- 
locked. A not less essential element is the appreciation of the diffe- 
rent displacements, which is more difficult than might be supposed ; 
sometimes in very muscular thighs, or in those swelled by inflamma- 
tion, I have found it impossible at first to discover which of the two 
fragments was on the inner or outer side, in front or behind ; and 
the degree of overlapping can only be estimated by one who is ex- 
perienced in measuring limbs. I have described, when speaking of 
the Diagnosis of Fractures in general, the manner of measuring the 
lower extremity when extended ; when it is flexed on the double in- 
clined plane, we may take for our two points the iliac spine and the 
edge of the outer condyle, always carefully putting the other limb in 
a precisely similar position. 

The prognosis results from what has been above stated, adding 
also our data as to the relative frequency of pseudarthrosis in the 
femur, and the influence of the plan of treatment adopted. 

The subject of treatment has greatly exercised the ingenuity of 
surgeons. But as this fracture is in some sort the type of fractures 
of the long bones, it follows that all that was said in connection with 
the general subject of their treatment is especially applicable here, 
and that there is hardly anything to be added to it. 

Thus, reduction is to be made according to the general rules. I 
would only observe that having recently had to treat two fractures 
which had just been sustained, I was surprised at the ease with which 
a single assistant restored the normal length of the limb ; a circum- 
stance which I observed also in the course of my experiments upon 



582 A TREATISE ON FRACTURES. 

animals. Hence we see the great advantage of promptness, every 
hour lost adding to the obstacles to be overcome. For the rest, our 
aim should be to bring the fragments end to end, as in Figs. 76 and 
77; if, after sufficient traction and proper coaptation, they slip and 
overlap afresh, we may presume that the fracture is oblique or com- 
minuted, and that reduction is impossible. 

To maintain the fragments in contact, every position and all kinds 
of apparatus have been made use of. Thus there have been tried 
successively : 

(1.) Simple extension of the limb, adopted, in the origin of our 
art, by Hippocrates, and preferred by many surgeons even at the 
present day. 

(2.) Complete flexion of the limb, recommended by Albucasis, who 
by approximating the heel to the buttock made the leg act as a sort 
of posterior splint. My experiments on the dead body have by no 
means led me to look favorably on this method, which does not ap- 
pear to have ever been employed by any one but its inventor. 

(3.) Semiflexion, the patient lying on his side; extolled by Pott, 
but now justly abandoned. 

(4.) Semiflexion, the patient lying on his back, and the double in- 
clined plane, or a mechanical bed, being used. 

(5.) Permanent extension, with the limb either extended or flexed, 
and the patient lying on his back. 

The choice of a posture has been already discussed in the article 
on the position to be given to the limb. In regard to keeping the 
fragments in place, the indications vary in different cases. 

In a simple fracture, without displacement, we may take our choice 
between flexion and extension, as well as between splints, cushions, 
pads, the immovable apparatus or the double inclined plane. 

A description of M. Velpeau's plan will suffice for all those which 
are based upon the principle of immobility. His apparatus consists 
essentially of a long roller soaked in dextrine, and three wide paste- 
board splints. One assistant holding the pelvis, and another raising 
the foot, the surgeon first surrounds the limb in its entire length with 
a dry roller ; afterwards he applies over this a single layer of the 
dextrinated bandage, reaching from the toes to the very root of the 
thigh. Over this first layer are placed the pasteboard splints, one 
in front, another behind, and the third on the outer side ; the first 
two extend the whole length of the limb, and the last passes up even 
to the external iliac fossa. These are kept in place by means of two 
more layers of the roller, carried up as high as possible over the hip, 
and made to surround the pelvis several times in the form of a spica.* 
To insure the extension of the limb during the period necessary for 

* Yelpeau, Lemons Orales, tome ii, p. 552, 1841. In his MSdecine Optratoire, 
published in 1839, this author recommended two splints reaching down only to 
the knee. 



A TREATISE ON FRACTURES. 583 

consolidation, the middle of a piece of strong bandage is put over 
the instep, and its two ends fastened at the foot of the bed, while 
another such strip is passed under the thigh, and its ends tied to the 
post at the head of the bed. When the bandage is thoroughly dry, 
these two bands are removed as useless. 

The use of splints has the advantage of greater simplicity, as well 
as of leaving the limb open to inspection. Two splints are neces- 
sary, both extending below the sole of the foot, and passing up, the 
outer one as far as the crista ilii, and the inner one nearly to the 
ischium. A splint-cloth is placed under the limb, reaching from the 
root of the thigh as far down as the heel ; in this the splints are 
wrapped so as to come within two fingers'-breadths of the limb ; the 
interspace on each side is filled up by a bag of oat-bran, of the same 
length as the splint, and the whole is bound together with five strips 
of bandage ; two for the leg, two for the thigh, and the fifth sur- 
rounding only the outer splint and the pelvis. 

As to the other forms of apparatus, I shall refer the reader to the 
article on that subject. 

If the fragments, although in contact, show any tendency to form 
an angle, this must be obviated by means of an outer splint fastened 
at the knee and at the pelvis, as in fracture just below the tro- 
chanters.* 

When the fragments, after being separated, are fortunately re- 
placed end to end, it is important to see that they do not again leave 
one another ; I have found nothing so efficient in preventing this as 
four small splints directly applied, one on each side of the thigh, and 
secured by two or three strips of lead-plaster. 

When complete reduction is found to be impossible, but when 
nevertheless the fragments are interlocked by some of their serra- 
tions, as in Fig. 75, the pressure of these immediate splints is of 
still greater value. I even employ them to advantage when the 
fragments only touch by their lateral surfaces ; it is no small matter 
to prevent too great a projection, and it is still more important, for 
the rapid and firm development of the callus, to keep the fragments 
pressed closely against each other ; there are in the Muse'e Dupuy- 
tren specimens in which the fragments are so separated that an in- 
terspace has had to be filled by the callus, as seen in Fig. 73 in a 
fracture just below the trochanters. 

Lastly, when the overlapping has presented insuperable obstacles 
to reduction, as in cases of oblique, multiple or comminuted fractures, 
we must resort to permanent extension, not indeed with the unattain- 
able end of restoring the full length of the limb, but to diminish the 
shortening as much as we can. I usually make this extension by 

* [I am informed that in his lectures, M. Mul<raigne speaks of having success- 
fully used, in oblique fractures of the femur, the screw apparatus which will be 
described in connection with fractures of the leg.] 



584 A TREATISE ON FRACTURES. 

means of the double inclined plane ; for those who prefer keeping 
the limb in the straight position, the simplest method consists in at- 
taching the pelvis to the head of the bed with a folded sheet, and 
hanging to the loop or gaiter surrounding the ankle a weight, by 
which continuous traction is exerted, and which may be increased or 
diminished at pleasure. 

In all cases, it is essential for the foot to be fastened in a proper 
position, to avoid any rotation of the lower fragment either inward 
or outward. I have pointed out, in my Anatomie Chirurgieale, a 
method of ascertaining that the fragments are in their true direc- 
tion. The limb resting on an even and solid plane, we should place 
the great trochanter and the external tuberosity of the femur on the 
same straight line, which should itself be parallel to the sustaining 
surface. 

Lastly, some surgeons have insisted on the importance of making 
the pelvis immovable upon the thigh, lest the upper fragment should 
be drawn out of place. The indication is doubtless a rational one; 
but experience has shown that it is not a matter of absolute neces- 
sity. Without therefore insisting upon it too rigidly, the surgeon 
will do well to bear it in mind, and especially to call the patient's 
attention to it. 

Consolidation being accomplished, we have to restore the motions 
of the limb; and this is often a delicate and difficult task; since, 
whatever care may have been taken to avoid too prolonged a confine- 
ment, the knee-joint will be found swelled and stiff. I have else- 
where mentioned this in a general way, and shall consider it specially 
in the next section. 

[The subject of fractures of the thigh has attracted much atten- 
tion among American surgeons, and various plans and modifications 
of treatment have been devised by them. The system of permanent 
extension has found the most general favor in all these; in fact the 
flexed position is advocated by only two of the leading surgeons in 
this country. 

The basis of nearly all the forms of extending apparatus is the 
splint of Desault, as modified by Physick and Hutchinson, of Phila- 
delphia. Physick carried the upper end of the outside splint nearly 
as far up as the' axilla, thus bringing the counter-extending band 
much more nearly into the line of the axis of the limb. Hutchinson 
fixed a block on the inside of the outer splint, (which was lengthened 
downward also,) a few inches above its lower end; the thickness of 
this block was such as to keep the extending band, which ran over 
its inner surface, in the line of the limb. This band was tied around 
the end of the long splint, by passing one end of the band through 
a mortise cut in the splint close to its extremity. The splint-cloth, 
junk-bags, confining-strips, etc., were of the ordinary well-known 
form. 



A TREATISE OX FRACTURES. 585 

The counter-extending or perineal band in common use was de- 
vised by Dr. Reynell Coates, and is made of buckskin, stuffed with 
bran or horsehair, so as to form a sort of thick fillet, with a tape at 
each end by which to fasten it to the upper end of the long splint. 
This may be made inextensible by using straps instead of the tapes; 
and if the patient is intractable arid persists in unbuckling the straps, 
a padlock may be easily put on, as proposed by Dr. J. F. Flagg, of 
Boston. — The latter end may be answered in another way, proposed 
by Dr. Xeill, of Philadelphia ; viz., by passing the tapes of the peri- 
neal band through holes cut near the upper end of the long splint, 
carrying them down along its outer surface, and tying them in a 
knot with the extending bands, which are brought up from the lower 
end in the same way. These may be tightened from time to time by 
twisting them with a small stick, on the principle of the Spanish 
windlass. — In the Xew York Hospital it is quite common to use a 
skein of woollen yarn as a counter-extending band, when the peri- 
neum is excoriated or tender. — Dr. David Gilbert, of Philadelphia, 
was, I believe, the first to publish a plan for making counter-exten- 
sion by means of adhesive plaster; his paper appeared in the Am. 
Journal of the Med. Sciences for January, 1851. He has since 
(January, 1858,) presented in the same periodical the history of seve- 
ral cases illustrative of his method, which has not as yet come into 
general use. — Dr. W. E. Horner, late of the University of Pennsyl- 
vania, proposed to moderate the pressure on the perineum by passing 
the counter-extending band through two strong loops on the outer 
surface of the inside splint, near its upper end, which was deeply 
notched ; the actual pressure being made by a strip of leather stretched 
across this notch. — Whatever material may be used, it is of very 
great importance frequently to examine the state of the skin pressed 
upon, and by stimulating frictions, the parts being carefully dried 
afterwards, to obviate the occurrence of excoriation as much as 
possible. 

This plan (Desault's, modified by Physick and Hutchinson,) is the 
one at present in use in the Pennsylvania Hospital; with, however, 
an important improvement in the manner of making extension, the 
introduction of which is due either to Dr. S. D. Gross, of Philadel- 
phia, to Dr. Ellerslie "Wallace, of the same city, or to Dr. Josiah 
Crosby, of New Hampshire. Physick had substituted for the figure- 
of-8 of the ankle, made with a bandage or handkerchief, a gaiter lined 
with buckskin, laced up in front, and fastened by tapes to the lower 
end of the long splint. This, however, not only required some skill 
in the making, but was extremely apt to induce irritation and ulcera- 
tion of the heel and ankle. It was therefore proposed to employ 
adhesive plaster in its stead; which may be done as follows: — take 
a piece of strong adhesive plaster, about two inches wide, and twice 
as long as from the seat of fracture to a point four inches beyond the 



586 A TREATISE ON FRACTURES. 

sole of the foot; just at the middle of this, place on the adhesive 
surface a piece of thin board, three inches square. Now cut a lon- 
gitudinal slit in the plaster, an inch in length, on each side of this 
bit of board; let the slits be equidistant from the edges of the strip. 
A bit of bandage, two or three inches wide and three feet long, is 
now to be passed through both the slits, its ends coming out one at 
each side; the piece of wood will thus be between the adhesive strip 
and the bandage. The limb being laid on a level surface, the toes 
pointing upward, the two ends of the strip, previously heated and well 
stretched, are applied one on each side of it; the bit of wood in the 
middle being about two inches from the sole of the foot, the extremi- 
ties of the strip will just about reach the seat of fracture. Three cir- 
cular strips, likewise about two inches wide, may be applied to keep 
the longitudinal one in place; but they should not entirely surround 
the limb, lest the return of venous blood be impeded. The bandage 
runs over the block, to be fastened as in any other apparatus. The 
object of the piece of board is simply to keep the strips parallel, 
and prevent their roping. Upon the adhesive plaster so applied, 
any endurable amount of traction may be made without its giving 
way ; and there is very little danger of excoriation, except just above 
the malleoli, which should therefore be protected by means of lint, 
raw cotton, or soap-plaster.— Dr. T. H. Bache of Philadelphia has, 
as was previously mentioned, (p. 198,) proposed a very ingenious 
double screw for making extension; one screw plays in a mortise 
cut near the lower end of the long splint, so as to be readily adapted 
to the width between the splints, according as the limb concerned is 
a large or a small one; at its inner end this screw has a ball, pierced 
so as to carry another screw at right angles to it, by which the ex- 
tension is to be graduated to the required point. The extending 
band is fastened to a straight cross-bar, which subtends a semi-ellipti- 
cal one; this latter is pierced at its middle by the upper end of the 
longitudinal screw, upon which it revolves freely. By turning the 
screw, the cross-bar is drawn down, and with it the foot. 

In the New York Hospital, each long splint is furnished with a 
block like that of Hutchinson, but somewhat thicker, which is bored 
for a longitudinal wooden screw; on the upper end of this screw is 
a brass hook, around which the extending band passes. 

It may be well to mention here another very excellent idea adopted 
in the same institution, viz., to buckle the upper end of the long 
splint to the patient's body by means of a broad belt of webbing, 
instead of the mere strip of bandage so commonly employed. 

As regards the filling up of the interspaces between the splints 
and the limb, many surgeons adhere to the old-fashioned junk-bags; 
some prefer padding the inner surfaces of the splints. It is neces- 
sary, especially when the latter plan is adopted, to apply compresses 
at different points ; and for this purpose the best material we can 



A TREATISE ON FRACTURES. 587 

use is to be found in scraps of old blanket, which can be folded very 
smoothly, and which do not, like raw cotton, form lumps here and 
there, or become sodden with perspiration. 

There remain to be noticed several other methods, differing essen- 
tially from the foregoing. Dr. William Gibson, now Emeritus Pro- 
fessor of Surgery in the University of Pennsylvania, proposed a 
very simple apparatus, based upon that of Hagedorn; it consisted 
of two long splints, reaching up to the axilla, and connected below 
by a transverse board to which both feet were fastened. The ends 
of the long splints were very much narrowed, so as to pass through 
mortises in the cross-piece, and were fixed at any point by means of 
pegs driven into them transversely, holes being provided for the pur- 
pose. Counter-extension was thus made from the axillae, and exten- 
sion by drawing down the foot-piece, to which both feet were made 
fast. The same surgeon sometimes employed a single inclined plane, 
upon which both lower extremities were laid, and the feet fastened 
to an upright board by means of gaiters ; the feet being thus fixed, 
the weight of the body was expected to make both extension and 
counter-extension. — Dr. Joseph Hartshorne, late of Philadelphia, 
proposed the following plan, based upon that of Boyer: an outside 
splint, with a padded, crutch-like head, to reach up into the axilla, 
and an inside one, with a similar head for the perineum; both these 
splints extended about eighteen inches beyond the sole of the foot, 
and were connected below by a firm cross-piece, bored for a wooden 
screw. This screw had at its upper end another cross-piece, sliding 
in a mortise in each splint, with a wooden sole to which the foot was 
to be tied. Counter-extension was made by the crutch-like head of 
the inside splint, and extension by means of the screw drawing down 
the foot-piece. — Dr. Henry Hartshorne has recently proposed making 
counter-extension from the tuber ischii, a thick block, hollowed for 
its reception, being placed between the upper ends of the two side- 
splints. He has also suggested a cross-bar placed above the patient's 
body, about on a line with the umbilicus. (See the Trans, of the 
College of Physicians of Philadelphia for 1855 and 1858.) — Dr. 
F. H. Hamilton, of Buffalo, in his " Report on Deformities after 
Fractures" presented to the American Medical Association in 1857, 
gives representations of three forms of splints used by him, but 
unfortunately without descriptions. — Dr. Dugas, of Georgia, makes 
his extension by means of a two or three-pound weight hung over a 
pulley at the foot of the bed, the resistance of the body making the 
counter-extension; side-splints are also used by him, but merely to 
keep the limb in line. — Various other appliances, more or less com- 
plicated, have been contrived for carrying out the principle of ex- 
tension ; among which may be mentioned those of Bowen, Sanborn, 
and the Burges; and the wire-cloth splints of Bauer, of New York. 
Although very good results may undoubtedly be obtained with any 



588 A TREATISE ON FRACTURES. 

of these forms of apparatus, they are not by any means essential to 
the panoply of the surgeon; descriptions of them may be found in 
Sargent's " Minor Surgery,'" in the pamphlet of the Drs. Burge, 
and in Dr. Hamilton's report, before alluded to. 

The flexed position is advocated in the United States chiefly by Dr. 
Nathan R. Smith, of Baltimore, and by Dr. J. C. Nott, of Mobile. 

Dr. Smith's plan for treating fractures of the thigh consists in 
bandaging the whole limb to an anterior splint, either carved out of 
wood, or made of wire and bent to suit each case ; the position given 
to the limb is one of moderate flexion, and the idea is to apply the 
bandage so neatly as to form for it a bed exactly adapted to its nor- 
mal shape. Extension is made by the suspending cord, counter- 
extension by the weight of the body; and Dr. S. says that the amount 
of extending force may be graduated by varying the point of attach- 
ment of the cord, so that the latter is more or less oblique in its di- 
rection. He claims to have obtained very good practical results from 
this plan, which is in general use among surgeons in Baltimore.* — Dr. 
J. C. Nott, of Mobile, uses a double inclined plane and short lateral 
splints ; the limb is bound down by means of straps, with vertical 
pins to keep it still more firmly in place. 

Splints of all kinds are discarded in fractures of the long bones 
by Dr. Dudley, of Kentucky, a simple roller being considered suf- 
ficient to retain the fragments.] 

§ VI. — Fractures of the Femur just above the Condyles. 

I give this name to fractures occurring an inch and a half or two 
inches above the patella, about three inches above the tuberosities and 
articular surface; that is, in an adult, somewhere in the lower third 
of the bone. The diaphysis increases in size in this region so as 
gradually to acquire a circumference half as large again as that of 
its middle portion ; while the compact walls of the medullary canal 
diminish in thickness, and the spongy tissue becomes more and more 
abundant, till at length it entirely constitutes the articulating ex- 
tremity. 

These fractures seem to me to be chiefly produced by direct causes. 
Thus of nine instances which I observed in the living subject, seven 
were direct and only two indirect, a very different proportion from 
that seen in fractures situated higher up. Sir A. Cooper does not, 
however, admit of any but indirect causes, such as a fall from a 
height upon the knees or feet. But he adds that he has seen none 
but very oblique fractures, and these are in fact generally due to in- 
direct violence. 

These fractures are almost always single, but for small and insig- 

* [For an account of another splint of Dr. Smith's invention, see a note to the 
article on Fractures just above the Malleoli.] 



A TREATISE ON FRACTURES. 589 

nificant splinters ; multiple or comminuted fractures are rarer here 
than anywhere else. They are most commonly serrated, but their 
serrations are smaller than those of the body of the bone; they as- 
sume a transverse direction, -which has even led to the idea that they 
were fractures en rave, [see p. 63.] I have already stated else- 
where that M. Denonvilliers believed that he had found in the Muse'e 
Dupuytren four or five examples of exactly transverse fractures of 
the femur, and all, singularly enough, at the lower third. I have 
had represented in Fig. 85 that one in which there is least ground 
for doubt ; and yet if the very marked obliquity of the upper frag- 
ment in front can be attributed to the absorption of its angle, the 
fractured surface of the lower one, which seems exactly transverse, 
presents a narrowing laterally which can only be explained by the 
detachment of a serration or of an oblique splinter. 

I would not deny that the spongy tissue very near the condyles 
may be broken exactly across; I only say that it has not hitherto 
been observed. 

Oblique fractures are more rare; Fig. 78 presents an instance of 
a fracture running downward, outward and a little forward ; some- 
times again it runs downward and inward, or perhaps downward and 
forward; and then generally the fragments overlap one another a 
good deal ; but there are cases in which the upper fragment is driven 
into the spongy tissue of the lower, constituting a fracture with pene- 
tration ; a very remarkable example of this may be seen in No. 143, 
in the Musee Dupuytren. 

The symptoms are in the first place those of fracture in general. 
Only when the fracture is very close to the knee, the joint shares in 
the swelling of the limb, and bloody or serous effusion occurs within 
the synovial membrane. Sometimes the capsule is broken, and thus 
there is a communication with the seat of fracture. 

There may be no appreciable displacement, in which case crepita- 
tion may be also wanting; the same thing may happen when there is 
impaction; but the shortening, and the projection laterally of one or 
the other fragment, sufficiently point out the nature of the injury. 
The fragments commonly slip from one another transversely, some- 
times only to a certain extent, but oftenest completely; and then the 
upper fragment is almost always carried in front of the other, unless 
when some special obliquity of the fracture gives it a tendency 
outward or inward. 

"When the fracture is seated quite low down, the riding forward of 
the upper fragment has the effect of pushing down the patella, and 
opposing an almost insurmountable obstacle to its being drawn up. 
In Fig. 85 the marked wasting of the upper fragment is doubtless 
owing to the pressure of either the patella or its ligament. In the 
oblique fracture shown in Fig. 78 the patella has been pushed down 



590 A TREATISE ON FRACTURES. 

even as far as the tibia, so as to have quitted the femur, thus under- 
going an actual luxation. 

Other complications may arise from the overlapping, when the 
upper fragment is very sharply pointed. Sometimes the capsule is 
perforated by it, and the joint entered; sometimes it passes outward, 
piercing the muscles, and reaching or even protruding through the 
skin. 

But what becomes of the lower fragment ? According to Boyer, 
its upper end is tilted backward into the popliteal space; this dis- 
placement, he adds, by which the anterior extremity of the condyles 
is directed upward, making a marked prominence at the upper part 
of the patella, gives a singular appearance to the knee. I am sorry 
to say that this description is wholly imaginary. Fig. 78 shows the 
upper fragment riding forward and outward; and the lower one is 
not in the slightest degree tilted backward. In Fig. 85 the upper 
fragment rides directly forward, and is even separated by several 
millimetres from the lower, which however remains parallel to it. I 
have never seen in the living subject, nor is there in any museum in 
Paris, a single example of the displacement described by Boyer and 
by others following him; the lower fragment passes up either di- 
rectly backward or to one side, and is never tilted over into the 
ham. 

Lastly, we sometimes observe angular displacement outward, but 
more rarely, and especially in a less degree, than in fractures seated 
higher up. Rotation by eversion of the foot is common to all cases 
in which the femur is broken. 

The course of these fractures presents no peculiarity, with the ex- 
ception of the effusion into the joint, which keeps up the swelling of 
the soft parts often even beyond the period necessary to consolida- 
tion. Sometimes on the contrary this engorgement, so close to the 
articulation, at length causes in it an inflammatory exudation and a 
true hyclarthrosis, even when the knee has escaped the primary con- 
tusion ; I have twice seen this complication arise in the course of the 
treatment. But it is mainly when union is complete, and when we 
have to restore to the limb its natural motions, that we should ap- 
prehend the occurrence of hydarthrosis ; a somewhat rude motion of 
the joint may develop it, either in a simple and almost painless form, 
or with all the pain and swelling of acute arthritis. It therefore 
takes a longer period for the recovery of free flexion of the knee; 
and in many cases this is never fully restored. 

The diagnosis is sometimes rendered obscure by the extent of the 
swelling which takes place ; but in proportion as this subsides, the 
characters of the fracture declare themselves in such a way as to 
leave no room for doubt. 

The prognosis is always rendered somewhat grave by the prox- 
imity of the joint. It is especially unfavorable when the upper 



A TREATISE ON FRACTURES. 591 

fragment bears the patella downward, wounding the capsule or the 
muscles ; suppuration may then ensue, and carry off the patient ; 
and the least of the evils to be apprehended is lameness, resulting at 
once from the shortening of the femur and the stiffness of the knee. 

Reduction should be attempted here with so much the more confi- 
dence, since the fractured surfaces are broader, and more easily kept 
in contact. Boyer made traction on the limb in the extended position ; 
Sir A. Cooper advises us to begin by flexing the knee, so as to dis- 
engage the upper fragment from the muscles, after which reduction 
is to be made with the limb straightened out. We may, if necessary, 
have recourse to this manoeuvre, putting the forearm under the ham 
so as at the same time to make extension; without this the flexion 
will only increase the overlapping, and still further entangle the 
bone. We should moreover be called in immediately after the acci- 
dent, since the swelling which soon ensues constitutes an almost 
invincible obstacle to our success. 

For the retention of the fragments, Boyer recommends the ordi- 
nary splints, or, when the fracture is oblique, the apparatus for per- 
manent extension; he also advises putting under the upper part of 
the ham a compress of linen or of charpie, to obviate the tendency 
of the lower fragment to tilt backward. We have said that this ten- 
dency does not exist, whence of course the indication disappears 
also. Sir A. Cooper, who has seen none but oblique fractures, 
recommends in all cases permanent extension with the limb straight. 

When the fragments are not very movable, I prefer using the 
double inclined plane, which by somewhat bending the knee tends to 
dimmish the consecutive stiffening of the joint. But when the frag- 
ments change their relations upon the slightest movement, I have 
more than once seen the weight of the pelvis draw the upper part of 
the limb inward, thus giving rise to a considerable angular displace- 
ment outward; in such cases I resort to the long lateral splints, 
putting a compress under the ham, not, like Boyer, to counteract an 
imaginary displacement, but with a view of slightly flexing the knee 
and obviating stiffness. 

In young persons external violence may give rise not to fracture, 
but to separation of the epiphysis. I have already mentioned else- 
where the unique case observed by M. Coural; the patient was a 
child of eleven years, whose leg was buried in a hole up to the knee, 
while his body was thrown forward. What was most remarkable in 
this case was, that the upper fragment was carried backward; and 
on proceeding to amputate, which became necessary, the condyles 
were found in front of the shaft, and so reversed that the articular 
surface was directed forward.* I do not know that this displace- 
ment has been observed in fracture just above the condyles; but it 
is well that its possibility should be pointed out. 

* Archiv. G6n. de Midecine, tome ix, p. 267. 



592 A TREATISE ON FRACTURES. 



§ VII. — Fractures of one Condyle of the Femur. 

This fracture is very rare, and has hitherto been hardly at all 
studied. Bichat, who first mentions it, would seem never to have 
seen it ; Sir A. Cooper gives but one instance of it, and that quite 
imperfectly related ; and but one specimen of it exists in the Musee 
Dupuytren. I have seen it in three cases; and these, with one re- 
ported by M. P. Boyer, constitute all the positive data we have 
concerning this fracture.* [Seven additional cases will be presently 
alluded to.] 

It consists in a nearly vertical division of the bone, striking the 
articular face near one or the other of the condyles, and directed 
from before backward, which goes up along the bone, deviating in- 
ward or outward according to the condyle affected, and terminating 
two, three, or even four inches above the joint ; the detached frag- 
ment forming a sort of pyramid, with the condyle for its base. 

The two condyles seem equally liable to be broken off; of the six 
cases above mentioned, three affected the outer one, and three the 
inner. 

The causes are very variable; sometimes it is the weight of some 
heavy body coming upon the condyles, sometimes a fall of the patient 
himself upon the knee in a state of flexion; sometimes again it is 
difficult to make out the mechanism of the injury; in Sir Astley 
Cooper's case it was caused by a wheel moving round, in the spokes 
of which the patient had both his legs entangled. 

The first phenomenon is severe pain, which is very soon followed 
by a considerable effusion in the knee-joint and at the lower portion 
of the thigh. The lateral mobility of the knee is greater than usual ; 
the broken condyle may be moved by itself when the swelling does 
not prevent its being grasped, and thus we may pretty certainly 
elicit crepitation; this is generally perceived also when any motion 
is impressed on the joint. The excessive swelling may however 
sometimes hinder its production, and the existence of the fracture 
can only be suspected from the displacement. 

In general, the fractured condyle tends to ride up above the level 
of the other, and to draw the tibia along with it. If the external 
condyle is the one concerned, the leg is abducted upon the thigh ; if 
the internal, it is adducted. This displacement is sometimes but 
slightly marked at first; but if the leg is carried inward or outward 
it is easily seen to go beyond the natural limits both of its adduction 
and abduction. In other cases, on the contrary, the displacement 
is so great that the tibia, in order to follow the fragment, is luxated 

* Malgaigne, Mdmoire sur la fracture de Vun des condyles dufimur; Revue 
Medico- Chirurgicale, April, 1847. 



A TREATISE ON FRACTURES. 593 

upon the still sound condyle, which consequently forms an abnormal 
prominence, on the inside or outside as the case may be; the two 
condyles are then also separated from one another; between them a 
wide hollow is perceptible ; the knee seems broader, and the patella 
less prominent, than normal. Lastly, in two cases of fracture of 
the outer condyle, the leg was very much rotated inward, involving 
a subluxation of the tibia behind the inner condyle. 

The course of these fractures presents no peculiarity but the enor- 
mous swelling which sometimes accompanies them; the callus is 
formed without any difficulty, and as in all fractures of spongy 
bones, there is no trace of the injury left in the interior. Hence 
they should require less time for repair than those of the diaphysis, 
and may be considered as healed at the end of forty days. 

[I have in my possession a very perfect cast of a specimen of 
fracture of the right external condyle, the history of which, how- 
ever, I do not know. The line of division runs downward and some- 
what inward, so as to separate the whole condyle, beginning above 
about two inches and a half from the articular surface. The patella 
and inner condyle are a good deal displaced inward, as is shown by 
the direction of the ligamentum patellae. The upper end of the 
fragment must have been plainly perceptible beneath the skin. It 
seems as if the foot had been everted by its own weight, rotating the 
tibia and the fragment outward. 

In a case which occurred during my residence in the Pennsylvania 
Hospital, a fracture of the inner condyle of the right femur was 
diagnosed, in a man who had had his leg crushed by a mass of stone ; 
the main symptom was the abnormal mobility at the point indicated. 
He died of his other injuries, but no dissection was allowed. 

Another instance, in which a scale of bone was separated from 
the inner condyle, the knee being also dislocated, is reported by 
Wells. (Am. Journal of the Med. Sciences, vol. x, [old series,] p. 25.) 

Kirkbride reports in the same journal, (vol. xvi, p. 32,) a case in 
which the outer condyle was broken by the kick of a horse ; there 
was angular deformity outward, and crepitation could be plainly per- 
ceived, but there was not much displacement. Union took place, 
and in eight or nine weeks the patient got up on crutches. He 
ultimately became able to flex the knee to a right angle. 

Brookes reports (Braithwaite 8 Retrospect, vol. xv, p. 149,) the 
ca^e of a boy with a compound fracture, from which a piece of the 
external condyle worked its way out after the lapse of three months 
and a half. A good recovery ensued. 

Dr. Godman, in his American edition of Sir Astley Cooper's 
"Treatise on Dislocations and Fractures of the Joints," mentions a 
case of detachment of the outer condyle by a blow with an axe. 

In the Report on Deformities after Fractures, by Dr. Hamilton of 



594 A TREATISE ON FRACTURES. 

Buffalo, a case is mentioned as having occurred to Dr. Crosby of 
New Hampshire, in which a fragment of the external condyle, as 
big as a walnut, was removed six months after its detachment by 
violence. No particulars of the case are given.] 

The diagnosis is often obscured by the amount of swelling ; and 
I have given, in speaking of the displacements, the means of form- 
ing it with some probability. 

The prognosis is rendered grave only by complications, or by irre- 
ducible displacement. 

With rational treatment, we may hope to restore the limb to its 
form, and to at least the greater part of its motion. 

Sir A. Cooper alone has dwelt upon the treatment. He advises 
stretching the limb out on a cushion; combating inflammation by 
means of leeches and evaporating lotions ; and as soon as the swelling 
subsides, surrounding the joint posteriorly and laterally as far round 
as to the patella with a trough of strong pasteboard, previously soft- 
ened in warm water so as to take the form of the part. This 
trough, held in place by a bandage, keeps the two condyles pressed 
toward one another; and the extended position has the advantage, 
according to Sir Astley, that the tibia maintains the two condyles 
on the same plane. 

The extended position has however the inconvenience of promoting 
the stiffening of the joint, which is mainly to be feared in consequence 
of these fractures. In cases in which the displacement was not very 
marked, Travers put the limb into semiflexion in a fracture-box; 
M. Grerdy kept it in the same position by means of cushions, and 
they would seem to have had no want of success. When the dis- 
placement is such that the tibia is subluxated, Sir A. Cooper's ap- 
paratus would probably be insufficient. 

I have treated a fracture of this kind by very slight flexion, the 
ham being supported merely by a pad, and the limb fixed in per- 
manent extension, also very slight. If in fracture of the external 
condyle the leg has a strong tendency toward abduction, a long 
splint must be placed at the outer side of the limb, so as to bear by 
its two ends upon the leg and thigh, while its centre, opposite the 
knee, is separated from it by a certain interval ; now a handkerchief 
folded into a wide cravat is made to embrace the knee, pressing it 
toward the centre of the splint, and thus obliterating the angle re- 
sulting from the abduction of the leg. An improper degree of 
adduction, in fracture of the inner condyle, should be obviated by a 
similar splint arranged at the inner side of the limb. The compli- 
cation of a subluxation would probably require two lateral splints, 
with two handkerchief-bandages to draw the femur and tibia in op- 
posite directions; I shall recur to this in speaking of luxations. 

Sir A. Cooper recommends that in order to avoid anchylosis pas- 
sive motion should be made use of after the thirty-fifth day. This 



A TREATISE OX FRACTURES. 595 

seems to me a very judicious plan, provided that the joint is entirely 
free from inflammatorv action. 



§ VIII. — Fractures of both Condyles at once. 

This fracture consists essentially in a vertical or oblique separa- 
tion of both condyles of the femur, communicating above with a 
transverse or oblique fracture in the lower third of the bone. 

It is more common than the preceding variety. Desault, who first 
described it, gives several cases; Deguise has published one;* Sir 
Astley Cooper another; I have myself seen it in three instances, 
and lastly there are four examples of it in the Musee Dupuytren, 
two of which, indeed, are from Desault's cabinet. [One very fine 
specimen of it is in the museum of the University of Pennsylvania.] 

The causes are most frequently direct; thus it has been seen re- 
sulting from a blow with a heavy beam, from the fall or pressure of 
a heavy body, as a barrel or a piece of casting, or from the kick of 
a horse. Sometimes we must ascribe to counter-stroke the upper 
fracture at least, as in falls upon the knee; but Bichat relates the 
case of a man who broke the condyles by lighting upon his feet; 
and here both fractures were equally attributable to counter-stroke. 

The symptoms are in the first place mainly those of fracture of 
one condyle alone; pain, effusion into the joint and into the tissues 
of the thigh, crepitation when the knee is moved, separation of the 
condyles, depression of the patella. But to these are joined also all 
the phenomena of fracture above the condyles; greater mobility 
above the joint than in the joint itself, and especially a notable de- 
gree of shortening of the thigh. It has indeed been stated, and not 
without probability, that fracture above the condyles may be trans- 
verse, and unattended with displacement; but hitherto, when com- 
bined with separation of both condyles, it has always been found to 
be oblique, and attended with more or less overlapping. Other dis- 
placements have likewise been observed; thus the shaft may be 
inclined at an angle with the lower fragments; the foot is sometimes 
everted, and twists the condyles in the same direction. Lastly, there 
is one symptom which belongs exclusively to the fracture in ques- 
tion ; it is that the two condyles, when the swelling of the soft parts 
does not prevent our grasping them, are movable upon one another 
and also upon the shaft of the bone. 

The course of these fractures hardly differs at all from that of 
fracture of either condyle alone; consolidation is in nowise impeded 
by the lesion of the joint, but the displacements are more marked 
and less easy of correction. 

* Journal de Chirurgie, by Desault, tome iv, p. 89. 



596 A TREATISE ON FRACTURES. 

The diagnosis can present no serious difficulty unless the swelling 
should be so great as to mask the vertical division of the bone, 
making that which passes across alone perceptible. 

The prognosis is somewhat grave; the patient is in danger, on the 
one hand of shortening of the limb with a troublesome projection of 
the upper fragment, and on the other of stiffening of the joint; or 
the injury may be so severe as to give rise to suppuration, threat- 
ening the destruction of life. 

As to the treatment, two principal indications were established by 
Desault: to correct the overlapping, and to bring together the 
separated condyles. He accomplished the first by means of his 
splint for permanent extension, and the second by a many-tailed 
bandage and two long lateral splints. These splints may be very 
properly replaced by the pasteboard trough of Sir A. Cooper, de- 
scribed in connection with the preceding variety of fracture; and a 
slight degree of flexion upon a double inclined plane would probably 
obviate, in part at least, stiffening of the joint. 

But the essential point is to make use of careful passive motion 
from the thirty-fifth or fortieth day. I have seen a patient who 
was treated by Guerbois on the plan of permanent extension; he 
had remained in bed five months; it was more than a year before he 
could leave off his crutches, and after eight years his knee was still 
swollen, with a flexion of only a few degrees ; the shortening was a 
little over an inch. Another, treated by Sanson with two lateral 
splints and no permanent extension, had worn the apparatus only 
fifty-six days; he could bend the knee nearly to a right angle, and 
in spite of nearly two inches shortening he could walk much better 
than the patient before mentioned. 

In this latter case the tibia was also broken near the knee, but 
without overlapping; so that the lesion was more serious than usual. 
I have had to treat a fracture of both condyles of the femur, com- 
plicated with fracture of the condyles of the tibia and with a pene- 
trating wound; the patient died on the twelfth day. But what I 
have to say concerning compound fractures will be more in place in 
the succeeding article. 



§ IX. — Compound Fractures of the Femur. 

I shall not here recur again to the points which were sufficiently 
treated of in the general article on Compound Fractures; but a 
grave question has been started in regard to compound fractures of 
the femur, and a few words in reference to it will not be inappro- 
priate. 

In a very curious memoir, Bibes has represented amputation as 
unavoidable in gunshot fractures at the middle portion of the femur, 



A TREATISE ON FRACTURES. 597 

and such was likewise the opinion of Larrey. But Ribes went still 
further; he regarded fractures at either end of the femur as nearly- 
equal in severity to those of its middle; he adds to these fractures 
of the leg also ; and comes to this peremptory conclusion : 

"That in almost all gunshot injuries of the bones of the lower 
limbs, the least delay in amputating may compromise the patient's 
life."* 

I shared in this opinion, like most military surgeons, until I saw 
the mortality which followed amputations of the thigh done upon 
the field of battle, when I abandoned it ; and for my own part, had 
I sustained a gunshot fracture of the femur, I would not submit to 
amputation unless under exceptional circumstances. I have had the 
satisfaction of finding my ideas in this respect confirmed by M. Mar- 
jolin; he had also tested by experience the value of amputation of the 
thigh for the lesion in question ; in 1814, at la Salpetriere, thirteen 
out of fourteen cases of this kind terminated fatally. 

What particularly fortified Ribes in his conviction was, that he 
had not found at the Hotel cles Invalides a single soldier who had 
had the femur fractured, with a wound of the adjoining soft parts. 
But of the four thousand then in the hospital, there was not one 
who had had the thigh amputated for fracture at the middle of the 
femur. Whence we see that one class had no more escaped than 
the other. 

Subsequently, between 1814 and 1822, Ribes received at the in- 
firmary of the Invalides seven patients who had survived gunshot 
fractures at the middle of the femur. M. Somme', arguing against 
that surgeon's opinion, has quoted three cases of cure after similar 
fractures. t I myself saw at Warsaw two persons whose thigh-bones 
had been broken in the middle, but were firmly united, although with 
deformity; and in the museum at Val-de-Grace is a femur consoli- 
dated in admirable position, from a Swiss of the royal guard, who 
was wounded in 1830 by a ball striking this bone just at its centre. 
[A pamphlet published by Saurel of Montpellier, in 1856, entitled 
u M&moire sur les Fractures des Membres par armes a feu" con- 
tains notes of three cases of gunshot fractures near the middle of the 
femur, all terminating favorably, and two of them without any very 
notable deformity.] It must however be allowed, that such success is 
extremely rare ; for instance, in his summary of the wounded of July, 
[1830,] M. Jobert gives three fractures at the upper, and three in 
the lower extremity of the femur, which were recovered from, but 
not one at its middle. % Perhaps it should be also stated, that he saw 
but one amputation for fracture of the femur; and there certainly 
must have been others. 

* Ribes. Mtmoire sur lafract. du tiers moyen du fe'rnur produile par armes 
a feu: Gazette Midicale, L831, p. 101. 
t Gazette Medicate, 1831, p. 133. 

X Jobert, Plaics d'armes d/eu, p. 262. 



598 A TREATISE ON FRACTURES. 

In order further to clear up this difficult question, I shall present 
a sort of statement of the fractures of the femur treated at the Hotel- 
Dieu in 1830. 

There were admitted thirteen cases of gunshot fracture of the 
thigh. In eleven of these no amputation was performed, in some 
because the patients refused to submit to it, while in others it was 
not proposed to them; six died between the fourth day and the 
twenty-fifth ; five recovered. Of these five cases, there was one at 
least, in a soldier, in which the fracture was at the middle of the 
bone ; the precise seat of the others is not stated. In the remaining 
two cases amputation was performed, and both the patients died. 
One of them, indeed, should not be taken into account, since a second 
operation became necessary.* 

We see then how grave these lesions always are, but also how 
decidedly the facts are opposed to the doctrine that we should always 
resort to amputation. The surgeon should duly take into considera- 
tion the conditions of the fracture, the state of the patient, and the 
surrounding circumstances, and base his judgment upon these data, 
without blindly obeying a general rule, which after all is perhaps only 
applicable in a minority of cases. 

Compound fractures of the femur, produced by ordinary causes, 
although less serious than those from gunshot, may still sometimes 
call for amputation. While we are not to postpone this too long, we 
should avoid too hasty a resort to it; since even compound fractures 
of the condyles, with wounds laying the knee-joint open, have been 
conducted to a favorable issue by Desault, Sir A. Cooper, and 
others. 

* MSnifcre, VHotel-Dieu en 1830, p. 312 et seq. 



CHAPTER XVII 

FRACTURES OF THE PATELLA. 

Fractures of the patella are not very common; of the 2328 cases 
of fracture at the Hotel-Dieu, they comprise only forty-five, at most 
one in fifty, or about four yearly. Hippocrates, Celsus, and Galen 
are absolutely silent on the subject ; and Soranus is the first to give 
any description of them. 

The cold season exerts a marked influence in producing them. Of 
the forty-five cases, twenty-seven occurred during the winter months. 

But this influence is feeble compared with that of sex. There 
were thirty-seven men to eight women, or nearly five to one. Of 
twenty cases observed by myself, only four were in women. 

The influence of age also merits attention. There was but one of 
these cases in which the patient was under seventeen years; I have 
myself seen only one case in a boy of eleven. From seventeen to 
thirty, there were ten cases; from thirty to fifty, twenty-one; from 
fifty to seventy, twelve ; from seventy to eighty, only two. Thus the 
absolute number, for the same space of time, is nearly the same in 
youth as in adult age; it diminishes as life advances, and becomes 
very small beyond seventy years. But taking into the account the 
population, the predisposition evidently increases steadily from one 
to the other of these great periods of life, the two last-mentioned 
cases representing in septuagenarians as large a proportion as the 
twelve preceding them in persons between fifty and seventy. 

The influence of old age seems especially marked in women; from 
seventeen years of age to fifty-five, they present but three fractures, 
but beyond this there are five. 

Fractures of the patella may be transverse, vertical [longitudinal] 
or multiple, [comminuted;] we shall treat successively of each of 
these varieties. 

§ I. — Transverse Fractures of the Patella. 

I shall include under this head not only single transverse fractures, 
but also such as present splinters too small to be considered as dis- 
tinct fragments. 

(599) 



x 



600 A TREATISE ON FRACTURES. 

The causes producing them are falls on the knee, direct blows, and 
muscular contraction. 

Falls on the knee may be considered as the most frequent cause 
of fracture of the patella ; of nine instances related by Boyer, five 
were ascribed to them, and I have myself observed, among nineteen 
cases, eleven thus produced. But it should be added that the result- 
ing fracture is quite frequently multiple instead of transverse. 

Much study has been devoted to the mechanism of this injury. 
Sue and Hevin thought that the patella bore by one end against the 
tibia, and by the other against the femur, and yielded in the middle ; 
a strange anatomical error. Boyer is hardly less out of the way in 
asserting that the knee must be considerably flexed for the patella to 
receive the full force of the shock. I cannot agree with Camper, 
that when a man falls on the knees upon an even surface the patella 
is untouched; but any one may convince himself by kneeling down 
that when flexion is considerable, as in Boyer's view, it by no means 
rests upon the ground; that it touches the ground as the thigh is 
brought to a right angle with the leg, and that it strikes the ground 
by its anterior face just when the flexion is in the least possible de- 
gree. Sanson has advanced a more ingenious theory, viz., that in a 
fall on the knees upon an even surface, the direct shock is sustained 
by the spine of the tibia; and the patella bearing by its centre only 
against the femoral condyles, its two extremities are drawn backward 
above by the muscles and below by the tendon, or ligamentum pa- 
tellae ; so that it yields at the middle, like a stick broken over the 
knee, in consequence of the muscular action.* 

The defect in all these theories is that no account is taken of the 
conditions of the fall itself, the knee being supposed always to be 
strongly flexed, and the patient to come down, as it were, bent up. 
This does indeed take place, as was just now shown, in ruptures by 
muscular contraction; but when the fracture results from the fall 
itself, in the first place the knee very often strikes some solid object 
raised above the surface of the ground, as a stone, a beam, or a step ; 
and again, in all cases the trunk is thrown forward; in one of my 
patients who fell in going up a staircase, this impetus was so great 
that his forehead struck one of the steps higher up, rendering him 
insensible. We may then regard it as settled, that the fall occurs 
with the least possible flexion, that the patella strikes upon its ante- 
rior face, at least in the majority of cases, and that the fracture is 
essentially direct. 

Transverse fracture may also be caused by a direct blow, without 
any previous fall ; but this is quite rare. Boyer has reported a case 
of transverse fracture resulting from the kick of a horse ; I know of 
no other instance. 

* Gazette des Hopitaux, December 19, 1835, 



A TREATISE ON FRACTURES. 601 

It is generally under the influence of violent muscular action that 
the patella is broken transversely; but the conditions of this action 
may be quite various. 

I have collected nine cases of fracture by muscular contraction ; 
one of my patients had a double one. Four times it occurred in 
going down stairs, once in running down a slope, twice in walking 
along on level ground, once in the effort of giving a kick ; once 
finally in a dancer, who heard a sudden crack while executing some 
movement, but made several steps, when his knee bent up and he fell 
backward. In the first seven cases, the fracture resulted from a 
false step, and by a powerful effort to bear back. Thus there ensued 
an opposition between the flexors, tending to incline forward at the 
same time the thigh and the body, and the extensors, tending to 
limit the flexion and preserve the equilibrium. The knee being 
slightly bent at the moment of the rupture, the patella may be con- 
sidered then as balanced upon the condyles of the femur, and drawn 
upon at its extremities by two powerful opposing forces ; Sanson's 
comparison would here be extremely appropriate, and the bone gives 
way at its middle like a stick broken over the knee. 

My last two cases are not without analogues in science ; Bichat 
speaks of a soldier who broke his patella in aiming a kick at his ser- 
geant ; and Hevin saw the same accident occur to a dancer who 
made a great effort in leaping. Here the extensor muscles, meeting 
with no resistance but the weight of the leg, first brought the limb 
into complete extension ; and then only, contracting inordinately, 
they tended to carry this action still further, or, since the ligaments 
of the knee constituted an invincible obstacle to this, to break the 
patella. The fracture then occurs at the moment of complete exten- 
sion ; and this mechanism is still more evident in the case related by 
Bichat of a patient who was cut for stone, and who, in a consequent 
convulsion, broke both patellre at once.* 

Lastly, this fracture may occur when the knee is a good deal bent, 
perhaps even when it is extremely so. Thus Boyer speaks of a 
coachman who, being in danger of falling from his box, made an 
effort to hold himself on, and heard instantly the crack produced by 
the fracture. The muscles were here opposed only by the weight of 
the body. Fielding has published the case of a woman who sustained 
the same injury in trying to lift a heavy basket ;f here again it was 
the weight of the body, but with the addition of that of the basket. 
Such cases must be quite rare, for I have found only these two. 

* [The action of flexion being more powerful than that of extension, the flexor 
muscles would in convulsions fix the knee in a very much bent posture, and then 
the extensors would certainly act to great advantage on the patella, Is LI not, 
therefore, probable that in the case last mentioned it was during a convulsive 
flexion that the rupture took place?] 

f London Medical Repository, 1823, vol. xix, p. 174. 



602 A TREATISE ON FRACTURES. 

An important remark in connection with these ruptures by muscu- 
lar contraction is that they are sometimes favored by an antecedent 
morbid condition of the patella. A patient admitted into Sanson's 
wards had suffered for six weeks from pains in the knee after a fall, 
when the fracture finally took place. I have reported, among other 
observations, the case of a member of our profession, who struck his 
knee severely against the wheel of a cabriolet, causing violent pain ; 
next day he was going down a staircase, when he slipped ; and al- 
though he held himself up by the baluster, he felt in the same knee 
a crack which too surely indicated a fracture of the patella. I have 
seen the same thing occur in a woman who a month before had sus- 
tained a bad contusion of the knee by a fall. It might indeed be 
alleged that the fracture had existed from the date of the first fall, 
and that the muscular contraction served only to break the fibrous 
bands still holding the fragments together. Perhaps it is so in 
some cases ; but we have seen how in other bones pre-existing pain 
shows a disposition to fracture by muscular action, and the patella 
certainly forms no exception to this rule. 

Transverse fractures present several varieties. In the first place, 
it must not be supposed that the bone is always broken directly 
across ; very often the fracture is oblique to a marked degree, and 
always from above downward and from without inward; sometimes it 
has an angle or a curve in its course, and often there are one or two 
small splinters. Muscular action can only give rise to purely trans- 
verse or oblique fractures ; all others are due to direct violence. 

The seat of the fracture merits careful attention. It has seemed 
to me, in the first place, that purely transverse fractures are found 
in the middle or at the lower part of the bone, and that in the upper 
half the division presents commonly some degree of obliquity. I 
have seen a transverse fracture so low down that a superficial ob- 
server might have taken it for a mere separation of the ligamentum 
patellae ; and I have seen another in which the upper fragment was 
not more than one-third of an inch in length. According to several 
cases which I have carefully compared, a curious relation exists be- 
tween the seat of the fracture and the determining cause ; thus when 
the body is thrown backward to avoid a fall, and the extensors thrown 
into contraction to maintain the equilibrium, the rupture occurs rather 
in the lower portion of the bone ; when the muscles act by endeavor- 
ing to increase the already complete extension of the limb, the bone 
yields at its upper part. But these conclusions need more ample 
proof. 

There may be simultaneous fracture of both patellae. Camper, 
Sue, Bichat, and Sir A. Cooper each saw an instance of this, and 
the two fractures represented in Figs. 79 and 80, and Fig. 84, be- 
longed to the same individual. 

But the most important point of difference is in regard to the de- 



A TREATISE ON FRACTURES. 603 

gree of separation of the fragments. Figs. 79 and 80 represent a 
fracture which was never suspected during life ; the fragments had 
remained in contact by their posterior surface, and the separation 
seen in Fig. 70 involves solely the articular cartilage ; there seems, 
however, to have been some slight separation at the outer surface. 
Fig. 81 is, on the contrary, an example of separation to an almost 
extreme degree. It may easily be seen how greatly the symptoms 
must vary in these two cases. 

The primary phenomena also vary according to the cause. Wh^n 
the bone yields to muscular action, there is at the same time severe 
pain and a cracking noise at the seat of injury ; the patient may 
still remain standing, or even advance some steps ; but if he falls 
down, as commonly happens, he falls backward, with the leg flexed 
under the thigh. On the contrary, when the fracture results from a 
fall upon the knee, the patient always falls forward, or possibly some- 
what sideways, the leg nearer to extension than to extreme flexion. 
Fractures by direct violence are also commonly attended by more or 
less extensive ecchymosis, which is wanting in most other cases. 

After the fall, the pain is sometimes so great that the patient can- 
not rise, and has to be carried. Often, however, he can rise and 
walk with very little assistance ; he then takes care to keep the leg 
stretched out as straight as possible, and by a sort of instinct he 
feels himself safer when walking backward and dragging the foot 
along the ground. 

We must not be surprised at the various attitudes assumed by our 
patients when carried. Some keep the leg bent, and these are mainly 
such as have lost the use of the patella by muscular contraction, 
and have fallen backward ; others keep it more or less extended, the 
least attempt at flexing it giving rise to excessive pain. The most 
usual position is however very slight flexion, or almost extension. 

In this state, the knee appears swollen and deformed, the promi- 
nence of the patella flattened and elongated ; and slight as may be 
the separation, a transverse hollow is perceptible between the frag- 
ments, or at least a flattened, quadrilateral space, increased by flex- 
ion, diminished by extension, and yielding under the finger so as to 
let it enter the hollow between the femoral condyles. When the 
effusion into the joint is considerable, this yielding is not so observa- 
ble ; but there is at least an evident degree of fluctuation. Above 
and below, the separated fragments may be recognised ; and lastly, 
on bringing these together I have always been enabled to elicit cre- 
pitation. 

When the contusion has been severe, the knee becomes the seat of 
actual inflammation, which may even induce a febrile movement. 
Generally, however, there is no fever; and sometimes the swelling 
itself is absent. 

The inflammation, of whatever degree, ordinarily subsides from 



604 A TREATISE ON FRACTURES. 

the fifth to the tenth day, when the hollow between the fragments 
appears deeper, and the separation more marked. Fluctuation may 
still be perceived; but from the tenth to the fifteenth day it becomes 
more obscure, and by the fifteenth or twentieth it completely disap- 
pears. This is due to the absorption of the liquid part of the effu- 
sion, and the organisation of a uniting tissue between the fragments. 
The separation diminishes in nearly the same degree as the fluctua- 
tion ; when this latter has disappeared, it seems to remain station- 
ary ; but I have sometimes seen it continue to grow less for a long 
time afterwards. 

I traced very carefully the course of these two phenomena in two 
patients, a man and a woman. In the former the fracture was direct; 
the separation on the eighth day was fourteen millimetres; on the 
fifteenth it was reduced to ten millimetres, and fluctuation had en- 
tirely disappeared between the fragments, although still perceptible 
above and at each side of them. In the woman the bone had yielded 
to muscular contraction; on the ninth day the separation amounted 
to thirty-five millimetres; on the fifteenth it was diminished to 
twenty-five, and the fluctuation was almost gone; on the eighteenth 
there was only a separation of two centimetres, and no trace of fluc- 
tuation. 

The consequences vary according to the conditions and degree of 
separation of the fracture, according to the nature of the callus 
formed, and especially according to the treatment employed. 

In general thirty or forty days suffice for the formation of a firm 
fibrous or even bony callus; but the stiffening of the joint will al- 
ready be very marked, and very difficult to overcome. This stiffen- 
ing has seemed to me to vary, (1) according to the degree of the 
inflammation; (2) according to the period of confinement; (3) accord- 
ing to the pressure exercised by the apparatus ; (4) and lastly, ac- 
cording to the time of application of the apparatus, whether before 
or after the occurrence of inflammation.* 

Thus in the cases I have published, we find : 

(1.) A simple roller, applied after the subsidence of the inflam- 
mation, and kept on for only thirty days; the stiffening was almost 
entirely dissipated by the end of three weeks. 

(2.) The same, applied on the first day and removed on the for- 
tieth; six years afterwards, the stiffening was still perceptible. 

(3.) A uniting bandage, applied on the tenth and removed on the 
sixtieth day; for two years the patient could not walk unless with 
the aid of a stick ; nearly three years afterwards, flexion could not 
be carried to a right angle. 

(4.) The same, applied on the twelfth day, and kept on for nearly 

* Malgaigne, De quelques dangers du traitem. gtne'r. adopts pour lesfract. 
de la rotule; Journ. de Chirurgie, 1843, pp. 201 and 236, 



A TREATISE ON FRACTURES. 605 

fifty days, in spite of pains in the joint; seventeen months afterwards, 
the knee could only be bent to 15° or 20° ; the patient was obliged 
to use a crutch. 

(5.) Simple position, maintained for twenty-four days; the patient 
had to use crutches for a year, and twenty-five years afterwards 
flexion was still incomplete. 

(6.) An apparatus, kept on only for three weeks; but rest in bed 
for five months; two years afterwards, no flexion beyond 90°; per- 
ceptible limping. 

(7.) Lastly, after the wearing of a starched apparatus for three 
months, union seemed to be bony; but at the end of the fourth 
month the leg could hardly be bent to 5° or 6°, and it was impossi- 
ble to say what was the prospect of its becoming more movable. 

Paulus JEgineta noted, as a consequence of fracture of the patella, 
the hindrance of movement, especially in making an ascent, due to 
the difficulty of bending the knee. Pare' insisted on a grave prog- 
nosis, declaring that he never saw a single patient cured so as not to 
limp; Fabricius Hildanus was of the same opinion; and the stiffen- 
ing was attributed to the formation of callus within the joint. We 
however see that this stiffening may in some cases disappear entirely, 
and that in general it diminishes in the course of time ; I would add 
that while it exists to a certain degree, the patients appear to me to 
experience less difficulty in ascending a staircase than in descending. 
This is because the stiffening interferes mainly with flexion, and the 
knee must be bent to a much greater degree in order to go down 
easily than to go up. The difficulty in ascending arises from another 
cause, very often combined with the one just mentioned, but the 
effects of which should be kept distinct in the mind; this is the union 
of the fragments by fibrous tissue, never so firm as either the patella 
or its ligament, and weak in. proportion to its length; so that the 
extensor muscles are doubly weakened, first by the want of solidity 
in their tendon, and second from their fleshy bellies being shortened 
and farther removed from their common insertion. The stiffening 
therefore interferes more essentially with flexion, and the fibrous 
structure of the callus with extension. 

The greatest separation within my knowledge was seen by Sir A. 
Cooper, and measured over four inches; then comes that figured by 
Camper after a specimen in the museum of La Haye, which exceeds 
three and one-third inches. Perhaps, however, we should not rely 
implicitly upon anatomical preparations; the fibrous tissue maybe 
much stretched in dissection; thus Fig. 81, correctly copied from 
a sketch, presents a separation of about two inches and a half, 
while before dissection it was only about two inches. It may be seen 
besides, that this elongation after death is the more considerable in 
proportion as the fibrous band is longer and thinner. 

Even during life the band may likewise be stretched by bending 



606 A TREATISE ON FRACTURES. 

the knee; but the shorter and thicker it is, the less marked is its 
yielding. In a patient in whom the fragments were but eighteen 
millimetres [three-fifths of an inch] apart during extension of the 
limb, flexion increased the separation to twenty-two millimetres; the 
fibrous band was very dense at its middle portion. I have seen, on 
the contrary, a man in whom the separation, amounting to an inch 
with the limb extended, was nearly doubled by flexion of the knee. 
The fibrous band was very thin ; the extension also was incomplete, 
and what is very remarkable, the upper fragment, perfectly movable 
under the fingers, was unaffected by all these motions, as if deprived 
of all connection with the other. 

The consequence of this separation is therefore a notable loss of 
power in the extension of the limb. Camper has stated, indeed, that 
in one or two years the power is recovered, whatever may have been 
the interval between the fragments; an evident exaggeration, since 
he himself speaks of a lady with a separation amounting to three 
fingers'-breadths, who still limped four years after the receipt of the 
injury. Mr. Benjamin Bell makes one inch the limit of separation 
allowing of the restoration of the firmness of the knee; Boyer fol- 
lows him ; M. Velpeau, on the contrary, asserts that he has seen the 
functions of that joint completely re-established, with an interval of 
two or three inches between the fragments. 

Such assertions are in my opinion only accounted for by some in- 
accuracy in examination; and for my own part, I have never seen 
the functions of the limb completely restored, even when the sepa- 
ration was limited to one-third of an inch. I have carefully ex- 
amined a member of our profession, whose case is cited as one of com- 
plete recovery ; the space between the fragments is about two-thirds 
of an inch, and the patient, tormented by a constant mistrust of the 
strength of his limb, would not dare to ride a horse on a trot, to go 
up two stairs at a time, or to run with any speed upon a level sur- 
face ; and especially is he unable to carry a load of any weight, his 
knee giving way if he attempts it. This inconvenience is much more 
serious to a working man ; I have seen a turner obliged to abandon 
his occupation because he could not stand long ; the porters at the 
market-house lose more than half their capability of carrying bur- 
dens ; I have seen one man come down from 400 pounds to 250, and 
another from 1200 to 400. Walking long distances becomes also 
more fatiguing; thus the man last mentioned, who could before his 
accident walk fifteen or twenty leagues in a day, was unable after- 
wards to exceed ten or twelve. Lastly, patients become fatigued 
particularly in making ascents ; which is explained by the effort ne- 
cessary for the extensor muscles to straighten the thigh and trunk 
on the leg as the foot is placed on each step. They however for the 
most part learn to go up without apparent difficulty, when once they 
overcome their instinctive want of confidence ; but the inconvenience 



A TREATISE ON FRACTURES. 607 

recurs when the step happens to be a high one, or if they try to 
mount two stairs at a time. 

Some are not so fortunate; sometimes the extension is so unsteady 
that I hare seen a patient who could not draw on his stocking with- 
out turning his leg to one side; sometimes the muscles have not even 
the power of producing complete extension. It is readily seen how 
vascillating this must render the gait. "We know," says Boyer, 
"several persons in Paris who are in this condition, and who are 
obliged to wear a sort of contrivance to hinder the bending up of the 
knee;" and then it is still necessary to steady the walk by a cane or 
a crutch. 

Lastly, this weakness may go still further, and the power of ex- 
tending the leg be almost entirely lost ; J. Hunter and Sir Astley 
Cooper have quoted very remarkable cases of this kind. 

These are undoubtedly very troublesome consequences, but they 
sometimes involve others of still greater severity. The weakness of 
the injured limb induces the patient to instinctively throw all the 
weight of the body on the other, especially in making any great 
effort ; the sound patella at length gives way, and is fractured in its 
turn. Meuschner reported the first example of this; Bromfeild 
again called attention to it; Camper says that he saw a good many 
such cases of secondary fracture; Sir A. Cooper also frequently 
observed its occurrence. 

This would however seem to me to be less common, and far less 
serious, than the rupture of the fibrous tissue connecting the primi- 
tive fragments. Heister was the first to mention the latter ; he 
knew of several instances. Morgagni reports two cases; others 
have been seen by Richter, Ortalli, Dupuytren, MM. Roux and Vel- 
peau ; I have myself seen a woman in whom the rupture occurred 
for the fourth time. It is asserted that union takes place as firmly 
as before : which however I am disposed to doubt. But it is only 
too certain that these ruptures of the callus may involve that of the 
skin, thus laying open the articulation. Sir Charles Bell reports 
such a case, the immediate cause being a fall backward; it became 
necessary to amputate the limb. I have seen a nearly similar in- 
stance ; the rupture of the fibrous band was attended with enormous 
ecchymosis, gangrene ensued at about the fifth day, and death closed 
the scene. Lastly, M. Seutin quite recently sought in vain to save 
a limb thus affected; after four months' suffering amputation of the 
thigh became the only resource.* 

Such are the unfortunate consequences which threaten patients 
with badly united fractures of the patella, as far as clinical observa- 
tion enables us to trace them. But pathological anatomy has given 
us some light, revealing especially a singular form of secondary dis- 
placement of the lower fragment. 

* Journal de Chirurgie, 1846, p. 120. 



608 A TREATISE ON FRACTURES. 

And in the first place, whence arise the variations in the degree 
of separation of the fragments ? Gulliver, having fractured the pa- 
tella transversely in some of the lower animals, found that when the 
fibrous tissue covering the anterior face of the bone was unbroken, 
the fragments remained in contact; while if this layer was divided 
they at once parted from one another by from four to twelve milli- 
metres.* This fibrous layer is therefore of importance in connection 
with this fracture ; and yet the complete destruction of it cannot in 
my opinion suffice to induce a separation even to a slight degree. 
Often, in the dead subject, I have divided it transversely along with 
the patella, with a knife ; as long as the section went no farther than 
the edges of the bone, the fragments could hardly be separated by 
the most powerful traction. To pull them apart by only half an inch 
or an inch, both sides of the fibrous capsule had to be divided; and 
to obtain an interspace of three to four inches, I was obliged to 
isolate the upper fragment by extensive longitudinal incisions through 
the aponeurotic sheath and muscular fibres of the quadriceps. 

Secondly, in what does the effusion consist which comes on so 
rapidly in the cavity of the joint? Sir A. Cooper, having divided 
the patella transversely in rabbits, found at the end of forty-eight 
hours that the space between the fragments was filled with coagulated 
blood. M. J. Cloquet verified the same phenomenon in man. An old 
man of sixty-six had his patella broken by a carriage-wheel passing 
over it, and died on the eigh'th day. The joint was enormously dis- 
tended with blood and synovia, and it was from the fractured surfaces 
alone that the hemorrhage had proceeded. f 

Sir A. Cooper traced the progress of organisation in rabbits. By 
the eighth day the greater part of the blood was reabsorbed; a 
plastic material occupied the space between the fragments. On the 
fifteenth day this material had assumed a smooth ligamentous aspect, 
and on the twentieth it was completely fibrous; finally, after five 
weeks, a fine injection showed the vessels running from the edges of 
the capsule into the interior of the new tissue; some, but only a 
small number, came from the bone itself. 

In the dog this process is not quite so quickly accomplished as in 
the rabbit; in man it is still more tardy. We have seen the stage 
which M. J. Cloquet's case reached by the eighth day. I have witnessed 
a dissection on the sixteenth day in a man of forty-three, whose 
thigh it had been necessary to amputate. Between the two frag- 
ments there was a clot of blood whose greatest consistency was in 
the vicinity of the fractured surfaces ; here it was of almost carti- 
laginous firmness, and seemed already to form one mass with the 
bone. J It is therefore the commencing organisation which causes 

* Gazette Medicate de Parts, 1841, p. 412. 

f Bulletins de la Faculty de Midecine, 1820, No. 6. 

% La Clinique des Hopztaux, June 14, 1828. 



A TREATISE ON FRACTURES. 609 

the subsidence of fluctuation by the fifteenth or twentieth day, as I 
have observed in the living subject; and it may be presumed that 
twice as much time is required to complete this in man as in the 
rabbit. 

I have studied the arrangement of the fibrous callus in a fracture 
of the patella of two years' standing. (See Fig. 81.) The skin was 
perfectly normal in aspect; but at the level of the callus the super- 
ficial fascia was greatly thickened, and strongly adherent to the sub- 
jacent tissue. The bursa over the patella was lost in these adhesions, 
not the slightest trace of it being perceptible. Without counting 
this reinforcement of the superficial fascia, the fibrous band was seen, 
when examined near the upper fragment, to be divisible into three 
layers, to wit: (1) the tendinous fibres covering the patella in the 
normal state; some of these were directly continuous with those of 
the callus, while the deeper ones, passing off from the upper fragment, 
lost themselves in a very marked prominence of the fibrous tissue, seen 
posteriorly about one-third of an inch below it; (2) fibres belonging 
to the periosteum, which lost themselves in the same fibrous mass; 
(3) short, thick fibres, interspersed with fat, arising from the whole 
fractured surface, forming the fibrous mass alluded to, and giving it 
a very considerable degree of consistency. Below this the callus 
was composed only of the superficial fascia and of prolongations of 
the outermost fibres of the tendon. It was therefore very thin in the 
middle, and only regained a notable thickness close to the lower 
fragment. At the sides, however, the fibres extended from one 
fragment to the other, giving these portions of the callus greater 
thickness and solidity. 

In another case, the fibrous tissue was thicker at the centre than 
laterally, but still showed the same increase in its mass toward either 
end. Nothing can be more irregular than these variations of form ; 
only if we compare, for instance, the thickness of the callus with 
that of the ligamentum patellae, we can easily see that the former 
could not withstand any severe strain. 

It has also been mentioned that the shortened muscles lose 
much of their power. This feebleness at length displays itself in a 
sort of atrophy; thus in the subject of Fig. 81 they were both 
thinner and paler than those of the sound side; the vastus internus 
had lost one-third of its normal thickness, and fat was already 
deposited among the fibres. 

The upper fragment, drawn up higher than in the normal state, 
makes for itself a sort of new articulation. In two patients in whom 
I have had the opportunity of dissection, the synovial membrane pre- 
sented opposite this fragment a narrowed opening, leading to a sup- 
plementary serous cavity; this cavity was just over the thickened 
and almost cartilaginous periosteum, and the bone beneath was 
slightly hollowed transversely. The fragment only preserves its 

39 



610 A TREATISE ON FRACTURES. 

articular cartilage at the points of contact of the new joint. We 
see for instance in Fig. 81 that the cartilage does not cover more 
than half of the upper fragment ; the rest is overspread with fibrous 
tissue and synovial membrane. In Fig. 84 Ave observe a small ellip- 
tical surface still retaining its cartilage; all around it are irregular 
eburnated prominences of the bone. 

Lastly, careful examination generally shows that this fragment is 
somewhat inclined upward and backward; but this inclination is 
nothing to compare to that of the lower fragment downward and 
backward. 

If we look attentively at Fig. 81, we see that the cartilaginous 
face of this latter fragment, in place of looking backward, is turned 
almost directly upward, and coated with the fibrous tissue of the 
callus. The fractured surface therefore looks forward; the anterior 
face downward, and the point, turned backward, is rounded off by 
pressure; so that in order to comprehend this curious malposition, 
the bone had to be divided vertically, keeping the articular cartilage 
intact. I have traced this version of the inferior fragment in the 
living subject ; I have three times had the opportunity of verifying 
it by dissection, and it may be recognised in the dried specimens in 
our museums. Fig. 82, for instance, was drawn from a preparation 
in the Muse'e Dupuytren; the fracture would seem horizontal in the 
upper fragment, while in the lower it presents a very marked obliquity 
downward and forward. This oblique surface is really that of the frac- 
ture, but changed in direction by the sort of version above described. 

Some forms of apparatus favor this movement; but apart from 
this quite secondary cause, it is the gradual and spontaneous result 
of the retraction of the ligamentum patellae ; the anterior fibres of 
which, longer than the others, also retract more, and draw down the 
anterior face of the lower fragment, into which they are inserted. I 
detached the ligamentum patellae as close as possible to the tibia, in 
the subject of Fig. 81 ; its average length was one inch, while that 
of the sound side was nearly twice as long. The ligament in this 
state of retraction was also very thick, as may be judged from the 
figure. Thus, the ligament in retracting had not only caused the 
lower fragment to describe nearly a quarter of a circle, but had 
drawn it down an inch below its normal position ; producing in this 
case a more marked effect than the muscles themselves had. 

These altered relations of the fragments undoubtedly interfere 
somewhat with free flexion of the knee ; I have several times, for 
example, seen the upper fragment caught by the upper edge of the 
articular face of the femur. But this is not the only obstacle ; for 
even the ablation of the patella does not render flexion perfect. In 
a case of this kind I have seen the crucial ligaments put strongly on 
the stretch ; and they were torn by bringing the heel up to the but- 
tock. There were in the joint neither false membranes nor adhe- 



A TREATISE ON FRACTURES. 611 

sions ; the stiffening, except the slight amount caused by the patella, 
was therefore due entirely to the contraction of the crucial ligaments. 

There remains lastly the great question as to bony union in trans- 
verse fractures of the patella. Pibrac even denied its possibility, 
and offered a prize of one hundred louis to any one who would show 
him a patella entirely united by ossific deposit.* Since that time its 
occurrence has been demonstrated by Camper, Sheldon, Boyer, and 
others ; I have sometimes seen it myself, but, what is very essential, 
never in simple transverse fractures ; there was always at least 
one small splinter broken off from one of the fragments. The spe- 
cimen represented in Figs. 79 and 80 affords a very fine example of 
union of a simple transverse fracture, but the separation was so slight 
that the nature of the injury remained undetected during life. 

In fact, if I mistake not, the whole difficulty arises from the 
amount of separation of the fragments. In simple transverse frac- 
tures, due almost always to muscular action, the patient falling back- 
ward with his knee strongly flexed, the rupture of the fibrous tissues 
is as extensive as possible ; the separation is generally greater than 
in fractures from direct violence, in which the knee is hardly bent at 
all. In this latter case the periosteum and the fibrous tissue behind 
the bone are in great part preserved, and this periosteum naturally 
plays an important part in the reparative deposit of bone. Indeed, 
in Gulliver's experiments, whenever the patella was fractured with- 
out injury to its periosteal covering, bony union took place ; when, 
on the contrary, this covering was divided, union was always fibrous. 

The cause of this rarity of ossific union is therefore that the plas- 
tic material thrown out partly by the fractured surfaces, but mainly 
by the periosteum, cannot fill up the interval between the fragments. 
In some cases we cannot but wonder at nature's efforts ; thus in 
Fig. 84, the lower fragment is surmounted by a bony stalactite nearly 
one-third of an inch in height, passing in front of the upper frag- 
ment, which it could not reach. In one of Camper's figures,f a 
similar prolongation is seen joining together, with the aid of a small 
intermediate splinter, the two principal fragments, while at each side 
the union is purely fibrous ; snowing the value of splinters. Some- 
times, lastly, analogous stalactites spring from the edges of the bone, 
nature's efforts at repair being misdirected. The cartilage takes no 
share in the process of reunion, as may be well seen in Fig. 79. 

On the whole, ossific union taking place in the majority of cases 
with some separation of the fragments, the bone remains elongated 
and deformed ; and I am not sure that this deformity does not inter- 
fere as much with the functions of the knee as union by fibrous tissue 
would. Boyer relates a case of this kind; the patella was elongated 

* Pratique Moderns de la Chirurgte, by Ravaton, tome iv, p. 336, note. 
t Dissert, de/ract. patellae et olecrani, Hagae-Com., 1789. 



612 A TREATISE ON FRACTURES. 

by about six lines ; the patient was obliged to use a cane for a year, 
and thirteen years afterwards the flexion of his knee was still limited. 
I have myself published a case of bony consolidation obtained by 
M. Blandin; the increase in length of the patella was estimated, 
during life, at eight lines ; at the end of the fourth month the leg 
could hardly be flexed five or six degrees. I sought in vain to find 
this man subsequently. 

The diagnosis is generally very simple ; a considerable separation 
strikes the eye at once ; if the separation is but slight we should seek 
to move the fragments in different directions, to elicit crepitation. 
Only excessive swelling may constitute an obstacle to this investiga- 
tion ; and this must be carefully treated. 

Nevertheless, when the separation amounts to only a few milli- 
metres, permitting neither movement of the fragments upon one an- 
other, nor the resulting crepitation, there is a cause of error which 
was pointed out by Sanson, and which I have several times observed. 
A fall on the knee upon some projecting body may break across the 
fibrous capsule investing the patella, without involving the bone itself; 
then with the finger or with the nail we recognise a transverse fissure, 
which simulates exactly that of a fracture without displacement. 
Sanson adds that sometimes the commencing inflammation of the 
knee gives rise to a rubbing sound when the knee is moved, resem- 
bling crepitus, and cites a case in point. A little attention will 
always suffice to recognise true crepitation; but the existence of the 
transverse fissure is more likely to lead the surgeon into error. 
When we have not for our information any mobility of the fragments, 
or any crepitation, there still remains one resource ; this is to try 
whether by slightly flexing the joint, the fissure can be widened, and 
whether a fine needle can be introduced between the fragments. We 
see, however, that there is some risk attending these measures, and 
often it is better to await the further progress of the case. Some 
days' rest will allay the pain due to mere rupture of the fibrous 
tissue behind the patella, but that of a fracture will still persist. 

In regard more especially to flexion of the leg we should observe 
extreme caution, to avoid the laceration to which it may give rise. 
J. L. Petit mentions a bone-setter who, for a traumatic lesion of the 
knee, undertook to make alternate flexion and extension of the leg, 
carrying each as far as possible ; the first attempt threw the patient 
into a syncope ; at the second, he died. 

The prognosis may be derived in great measure from the preceding 
considerations, but it varies somewhat, mainly according to the treat- 
ment employed. 

A great many plans and forms of apparatus for treating fracture 
of the patella have been devised, which may however be classed un- 
der three principal heads. The first aims at securing the firmest 
union, and consists essentially in keeping the limb immovable ; the 



A TREATISE ON FRACTURES. 613 

second has for its main object the prevention of stiffening, and is 
distinguished by making extensive motion of the joint long before 
the process of union is completed; the third, being a combination of 
the two former, may be called the mixed plan. 

First Method. — This seems the most natural, and was the one 
earliest employed. It is itself divided into two secondary methods, 
according as mere position is relied on, or as contrivances are used 
for approximating the fragments. 

Paulus iEgineta and Pare* merely kept the leg extended, by means 
of splints, long compresses of straw, or troughs. J. L. Petit did 
indeed advise also the putting of the leg upon a pillow raised toward 
the foot ; but with no other idea than that of more certainly securing 
extension, and favoring the return of the blood. In 1772, Valentin 
showed that merely extending the leg did not sufficiently relax the 
rectus femoris muscle, and recommended raising the heel as much as 
possible. Accordingly he arranged pillows in an ascent beneath the 
thigh and leg, at the same time putting the foot into a slipper, at- 
tached by three bands to a body-piece surrounding the chest of the 
patient. Richerand retained the cushions, but abandoned the slipper. 
Sabatier, remarking that the absolutely straight position induced in- 
supportable pains in the ham, thought that the knee ought to be bent 
to a slight degree ; but in order not to lessen the relaxation of the 
rectus femoris, he advised that the flexion of the thigh on the pelvis 
should be increased. With a view also of preventing the pillows 
from sinking in, he had sewed to each corner of the one supporting 
the leg a riband, by which it was suspended from the curtain-frame; 
and this was the first attempt at suspension without a machine.* 

Lastly, in 1789, Sheldon showed the impropriety of the extended 
position still more plainly than Valentin had. In a subject six feet 
and one inch in height, he found the distance between the two points 
of attachment of the rectus femoris, the hip and knee being straight- 
ened out, to be twenty and a half inches, and with the hip bent at a 
right angle, only eighteen inches. Hence he advised, and most 
English surgeons follow out the idea, that the patient should be 
seated in bed, his body vertical or even inclined slightly forward ; 
and that when this posture becomes fatiguing, the body should be 
allowed to lean backward, the limb being proportionately raised. f 

* Valentin, Recherches crit. sur la chir. moderne, Amsterdam, 1772 ; Riche- 
rand, Mem. sur les fract. de la rotule, in the Minx, de la Socie'te' M6dicale 
& Emulation, tome iii ; Sabatier, M6m. sur la fract. en travers de la rotule; 
Mem. de V Acad, des Sciences, 1786. I do not know where Boyer found the 
statement that Sabatier made his patients lie on the side. 

f Sheldon, An Essay on the Fracture of the Patella, etc., London, 1789. I 
have not been able to procure this work, and quote from Camper and Monteggia. 
[I have consulted the book in question, but find nothing said of seating the pa- 
tient in the manner mentioned; the only plan spoken of is, to lay the patient on 
either side, with the injured limb flexed ; the amount of flexion being regulated 
by the evident relaxation of the extensor muscles.] 



614 A TREATISE ON FRACTURES. 

Whatever position may be preferred, it is too evident that although 
the space between the fragments may be diminished, it cannot be 
obliterated. There are two muscles to be relaxed, the triceps [com- 
prising the crureus and the two vasti] and the rectus femoris. The 
former, which has received scarcely any attention, is much the more 
powerful of the two ; the only means of relaxing it is to keep the leg 
in a straight line with the thigh; but both clinical observation, and 
experiments on the lower animals, show that mere extension is insuf- 
ficient to enable us to bring together the two portions, if this muscle 
be divided transversely.* Hence it is very nearly useless to keep 
the patient in the fatiguing posture prescribed by Sheldon, which 
does not affect the triceps at all ; that advised by Valentin is to be 
preferred, not because it is more efficient, but because it is more sup- 
portable. But it requires for its maintenance some surer means than 
cushions or even lateral splints. Desault was the first who conceived 
of putting a strong splint beneath the joint itself, and it is better to 
have a board of a proper width reaching from the buttock to the 
heel. 

But since the desired end is not attained by extending the leg, 
ought we not to make use of slight flexion, in order to obviate the 
severe pains sometimes observed by Sabatier, as well as by Boyer 
after him ? I should say in reference to this that the pains are gene- 
rally of short duration, that they may in most cases be prevented 
by applying compresses under the ham, so as to hinder any distor- 
tion of the joint, and that we might as well at least wait till the po- 
sition is complained of before changing it. In fact, the slightest 
bending of the knee, increasing the separation, increases the tension 
of the triceps, which is by far the greatest difficulty with which we 
have to contend. 

Our apparatuses require therefore to be seconded by position; but 
position cannot be sufficient without some apparatus. 

These contrivances have been so multiplied, that in order not to 
be lost in a barren enumeration, we must class them according to 
their principal types ; these are founded on their mode of action. I 
make thus four groups, viz. : 

(1.) Apparatuses for circular pressure, having for their object to 
embrace more or less exactly the contour of the bone. 

(2.) Apparatuses for parallel pressure, acting on each fragment, 
across the axis of the limb. 

(3.) Apparatuses for concentric pressure, acting from above down- 
ward and from below upward upon the edges of the respective frag- 
ments. 

(4.) Lastly, such as act only on the upper fragment. 

The first suggestion of circular pressure is to be found in Albu- 

* See my Anat. Chirurgicale, tome i, p. 107. 



A TREATISE ON FRACTURES. 615 

casis, who covered the patella with a round splint, that is, a splint 
perforated in the centre, and kept in place by a bandage ; this appa- 
ratus was approved of or modified by Guy de Chauliac, J. de Vigo, 
and Bassuel, and was still employed at the Hotel-Dieu in Paris, in 
the latter half of the eighteenth century. We should also mention 
(1) Purmann's ring, made of twisted iron wire, and wrapped in a 
double covering of leather; (2) the petit chapeau, pileolus, or little 
hat of Meibomius, modeled upon the sound patella, sufficiently con- 
cave to be stuffed with cotton, and bearing by a wide brim upon the 
neighboring parts. Sometimes the author cut this instrument (which 
was probably made of wood or cork) in half, in order to apply it 
more readily, fastening the two portions subsequently with an iron 
ring; and lastly, in case of a wound, he left a fenestra in the centre; 
(3) the wooden cap of Kaltschmidt, which would seem to be an imi- 
tation of the petit chapeau of Meibomius, etc.* Nothing like these 
is in use at the present day ; they cannot indeed afford either the 
accuracy of application or the power of those which succeeded them. 

The apparatuses acting by parallel pressure have been iftore suc- 
cessfully used. The first of these was devised by a mechanic of 
Leyden, named Muschenbroek ; it was described by Solingen, pub- 
lished in France by Blein, and almost at once copied by Arnaud, 
who gave it his own name. As modified by Arnaud, it consisted of 
a trough of sheet-iron or tin placed beneath the ham, provided with 
a fenestra so that this part might be moistened if necessary, and 
having holes cut for screws close together along each lateral margin. 
Two wide concave plates with holes corresponding to these, were 
applied one above and the other below the patella, and fastened by 
means of screws passed through the holes above mentioned. It 
is probable, though not stated, that the limb was first protected by 
compresses from undue pressure. f 

I have dwelt upon this contrivance, both because it was the ear- 
liest, and because it became the type on which all the rest were 
modeled. In fact, if we substitute for the trough of metal one of 
wood or leather, or even a simple splint to support the leg and ham ; 
if we replace the two wide plates intended to approximate the frag- 
ments by narrower ones, semicircular or horseshoe-shaped, making 
them, provided they are duly padded, of iron, cork, or leather; if we 
confine these to the trough by straps passing around transversely; 
then if we bring them toward one another by means of screws ar- 

* See the MSmoire of Bassuel, analysed in the Bibliotfoque of Planque ; the 
thesis of Allouel, Paris, 1775 ; and the thesis of Meibomius, 1697, reproduced in 
the Diss. Anatom. of Haller, tome vi. Kaltsehmidt's apparatus is represented 
in Richter's Atlas. * 

t Bee for the account of this machine Solingen, quoted by Richter; Carengeot, 
Traits des Instruments de Chirurgie; La Chirurgie Complete, by Leclerc; and 
Duvernev's treatise. 



616 A TREATISE ON FRACTURES. 

ranged in any way, at the sides or in the middle, or even by means 
of straps running alongside of the patella; or if we use, instead 
of all this, two thick compresses, one above and the other below the 
bone, pressing them together by bandages or handkerchiefs, — we 
have the forms of apparatus proposed by Bucking, Evers, Bottcher, 
Aitken, Lampe, Graefe, Morgridge, Mayor, etc.* The uniting band- 
age, first recommended by Heister, and adopted by Larrey and 
Dupuytren, is still sometimes employed in our hospitals ; but the 
relaxation of the material composing it renders it the least reliable 
of all our appliances. 

The origin of the plan of concentric pressure is to be found in the 
figure-of-8 made with a double-headed roller, as described by Lavau- 
guyon. To this were soon added graduated compresses of linen, or 
plasters, so as to act more forcibly upon the fragments ; such is the 
apparatus described by J. L. Petit; and this simple plan has gained 
numerous partisans. But the unavoidable occurrence of relaxation 
of the bandages soon led to the employment of firmer materials; 
hence tlte contrivances of Ravaton, Allouel, Boyer, Buirez, Assalini, 
etc., which are all composed of a straight trough, with a strap em- 
bracing each fragment, and fastened at the same level on each side; 
except that of Ravaton, in which the trough is curved so as slightly 
to flex the leg. I shall describe only Boyer's apparatus, as com- 
bining great efficiency and great simplicity. 

This consists of (1) a hollow wooden splint long enough to reach 
from the middle of the thigh to below the calf, deep enough to take 
in two-thirds of the thickness of the limb, and well padded inside, ■ 
having at about the middle of each edge nails, with rounded heads, 
ten or twelve millimetres apart ; (2) of two straps about an inch in 
width, whose middle third is formed of buffalo-hide, padded with wool 
and lined with chamois-leather, and the outer third on each side of 
calf-skin, with holes four or five millimetres apart; (3) of five or six 
loops of ribbon or bandage. The limb is placed in the trough, all 
the interspaces being filled with cotton; then while an assistant ap- 
proximates the fragments, the straps are arranged one above and the 
other below the patella, their extremities being fastened at either 
side, it may be on the same nail; or sometimes the upper strap 
catches on the lower nail, and the lower strap on the upper nail. 
Compresses dipped in some antiphlogistic solution are now laid over 
the patella, and the whole is confined by means of the loops knotted 
upon one side of the trough, or perhaps with a roller. 

Quite recently, M. Velpeau has again adopted the figure-of-8, giv- 
ing it however by the addition of dextrine a firmness, of which sim- 
ple bandages are destitute. The limb being moderately extended, 

* Most of these are given in Richter's Atlas ; that of Morgridge may be found 
in Amesbury'swork. 



A TREATISE ON FRACTURES. 617 

and the two fragments brought as nearly together as possible, the knee 
is first covered with fine dry linen ; after which graduated compresses 
are placed transversely above and below the patella, and confined by 
oblique turns of a roller passing beneath the ham. This done, the 
first layer of the dextrinated bandage is applied, reaching from the 
foot to the fold of the groin. A moistened sheet of pasteboard is 
now disposed beneath the limb, from buttock to heel, and the second 
and third layers of the dextrinated bandage complete the apparatus. 
A wooden splint is temporarily applied until the whole is dry. 

I have also seen the figure-of-8 applied by M. Gama, by simpler 
and much more powerful means. Instead of ordinary bandage, 
M. Gama uses very long strips of adhesive plaster, which when once 
put on over the graduated compresses, are not so likely to relax as 
the dextrinated apparatus is, at least before its entire consolidation ; 
they moreover leave the patella exposed, and enable us to increase 
or diminish the pressure as the case may require.* 

There remain to be considered apparatuses acting solely upon the 
upper fragment. The principle was suggested by Pott, who, regard- 
ing the lower fragment as essentially immovable, applied merely a 
small compress above the upper fragment, retaining it in place by a 
moderately tight bandage. The idea obtained favor both in England 
and Germany; and hence the more complicated contrivances of 
Benjamin Bell, Bottcher, Sir A. Cooper, Amesbury, etc. Bell and 
Amesbury, however, both kept up a certain action upon the lower 
fragment, by means of a transverse strap or plate drawn toward 
the upper one as in the apparatus for parallel pressure; but their 
essential aim still was to draw the upper fragment downward by 
means of loops attached to a shoe worn by the patient. Bell used 
a single strap fastened at the point of the shoe; Bottcher dispensed 
with the shoe by employing two straps meeting beneath the sole of 
the foot, like a stirrup. Sir Astley Cooper encircled the limb above 
the upper fragment with a leather band, fastening it with buckles ; 
from one side of this there descended a single long strap, which 
passed under the sole, came up along the other side of the leg, and 
was again attached to the circular band. 

All apparatuses of this sort have two grand defects; in the first 
place, by drawing down the upper fragment without fixing the lower, 
we merely push the latter downward, thus voluntarily losing the ad- 
vantage of reciprocal pressure of the two fragments, so important in 

* Adhesive plaster has also been employed by Alcock, in England; see his 
"Practical Observ. on Fract. of the Patella," etc., analysed in the London 
Med. Repository. 1824, vol. i. p. 490. 

[Alcocks plan was to carry strips obliquely across, each way, above the 
patella and down to the ham ; the upper fragment being thus in the angle be- 
tween the two sots of .-trips. He used also a compress, and a loosely applied 
bandage ; and speaks of the strips as not essential.] 



618 A TREATISE ON FRACTURES. 

insuring their contact and hastening consolidation ; secondly, we 
have seen that the lower fragment is apt to be drawn down and tilted 
over by the retraction of the ligamentum patellae, and hence that we 
must act upon this fragment as well as upon the other. 

On the whole then, mere position being almost always insufficient, 
and apparatuses acting by circular pressure or by pressure on but 
one of the fragments being excluded, there remain only those which 
act by parallel and by concentric pressure. Now if there is any 
fact in surgery which is incontestable, it is that of their inefficiency 
in procuring regular and firm union. This inefficiency is due to 
various circumstances. 

In the first place, the patella does not present such external pro- 
minences as to allow these apparatuses sufficient purchase. The 
extensor tendon is not inserted behind the edge of the bone, but 
rather in front of it, since some of its fibres pass over its anterior 
face; and the same is true also of the ligament which completes it. 
We must therefore depress both these strongly, in order to make 
hollows above and below the bone into which the straps may sink. 
Now the contractions of the muscles tend constantly to efface these 
hollows, raising the straps to a level with the anterior face of the 
bone, and making them slip for want of purchase. When by strong 
pressure we obviate this danger, another instantly arises, which I 
believe I was the first to point out. 

This is, that in forcing the tendon into the hollow above the con- 
dyles, and the ligament into the depression between the femur and 
tibia, we make the fragments tilt strongly backward, so as to widely 
separate the fractured surfaces in front. They may indeed be thus 
brought into contact, but the contact is partial and limited to the 
posterior edge of the fracture; in front there remains an interspace 
so marked that the skin may sometimes be pushed into it. I was 
first struck with this in a man who came to the Maison Royale de 
Sante to be treated for a fractured patella, which had united by 
fibrous tissue. There was no swelling of any kind; the muscles 
were supple and easily stretched, so that I could readily bring the 
fragments in contact by their posterior edges, but the hiatus in front 
still remained, and could not be obliterated. Since then, out of a 
good many recent fractures, in which the swelling always obscures 
the part somewhat, I have occasionally thought that with the fingers 
I made perfect coaptation, but this was always lost on substituting 
any apparatus for the fingers. In experiments on the dead body, 
pulling upon the muscles to represent their natural contraction, I 
have shown M. Mayor of Lausanne that his apparatus is as liable as 
any other to this serious inconvenience. 

When we examine fractures of long standing, united only by 
fibrous tissue, it is perhaps difficult to distinguish in regard to this 
phenomenon how much is due to retraction of the ligamentum patellae, 



A TREATISE ON FRACTURES. 619 

and how much to the apparatus used. But when there has been bony 
union, the former cause is excluded. Now in the case reported by 
Boyer, the injured patella was longer by six lines than the sound 
one, and in the figure the transverse fossa separating the two frag- 
ments anteriorly was recognisable, explaining the increase of length. 
In M. Blandin's patient I found the injured patella longer than the 
other by eighteen millimetres ; through the integuments there could 
be perfectly perceived a transverse fossa, limited by the anterior 
edges of the fractured surfaces, and having a width exactly equal to 
the increase in the length of the bone. 

This tilting of both fragments is never so marked as when the 
fracture occupies the middle portion of the bone. When the frac- 
ture is near either extremity, it is only the larger fragment which is 
thus inclined, the smaller being simply depressed along with the 
tendon or ligament inserted into it. Monteggia -was struck with this 
fact; in a fracture seated in the upper fourth of the bone the upper 
fragment was deeply sunken, while the other was rendered promi- 
nent; to efface this prominence, it was necessary to make pressure 
directly upon it. M. Ph. Boyer saw likewise, in a case in which the 
point of the bone was torn off, the upper fragment so tilted that the 
least pressure on the ligamentum patellae turned it back, so to speak, 
and that he had to use means bearing directly on the projecting frag- 
ment in order to retain it in place.* I have myself observed analo- 
gous cases. 

Lastly, there is one more disadvantage which has also escaped 
observation. The lower strap bears quite accurately upon the point 
of the patella, which is nearly in the median line; but the upper 
one presses upon the base of the bone, which is directed obliquely, 
its outer extremity being nearly one-third of an inch above the level 
of the inner. The pressure is therefore greater at the outer than 
at the inner side, the approximation more close, and the union more 
solid. Thus in Boyer's specimen, before alluded to, the callus is 
complete externally, but leaves a notable gap internally. Boyer has 
himself remarked that the upper fragment was tilted away from the 
other so much as to form with it an angle of 130°, opening outward. 
I have met with the same appearance in fractures united by very 
short fibrous bands, of which the outer portion is always the snorter. 

With apparatuses for parallel or concentric pressure, therefore, 
we generally obtain only fibrous union, for want of coaptation ; and 
when we do obtain coaptation, it is usually still deficient at the an- 
terior and inner part. The only advantage of the former method, 
as hitherto applied, is to diminish the separation of the fragments, 

* See the additions in the new edition of Boyer. M. Ph. Boyer alleges in this 
same passage, that the tilting of the fragments is owing solely to improper ap- 
plication of the bandage, adducing as proof the success of his own cases. I 
regret that I cannot agree with him. 



620 A TREATISE ON FRACTURES. 

and thus to procure a shorter and firmer uniting band. But this 
advantage is quite dearly bought at the expense of the stiffening 
which almost inevitably attends such treatment; and hence surgeons 
have sought some other means of attaining it. 

Second method. — This plan was devised in England at about the 
middle of the last century. Warner, in 1754, speaks of it as adopted 
by a majority of the London surgeons ; Camper introduced it into 
Holland, and Flajani into Italy.* These authors differ somewhat as 
to the manner of its application. 

Thus Warner, having to treat a young woman for a broken patella, 
approximated the fragments within an inch, and kept them in place 
at first with a bandage. But some days afterwards he began care- 
fully to make alternate flexion and extension of the knee, and re- 
peated the operation daily for about six weeks, when he considered 
the cure to be complete. 

Camper likewise applied a bandage during six, eight, or ten days, 
and then made his patients get up and walk about. 

Lastly, Flajani dispensed with all bandages, treating the swelling 
at first by position and fomentations. The swelling having subsided, 
he directed the patient to bend the knee in bed several times a day, 
and after a day or two to get up and walk, first with crutches and 
then with merely a stick. Of three patients whose cases are given, 
one got up on the thirteenth day, and the other two on the ninth; 
one could walk freely without a stick by the eighteenth day, the 
second by the twenty-sixth, and the third not until the sixty-fourth. 

It is evident that the stiffness so frequently resulting from treat- 
ment by the first method is obviated by this one; and Pott asserts 
that the patients who walk best after fracture of the patella are 
those who have been made to move the knee from the time of sub- 
sidence of the inflammation, and in whom a certain interval exists 
between the fragments. We have, however, seen the true value of 
this union with an interval; and several surgeons have sought to com- 
bine the two plans, so as to secure the suppleness and at the same 
time the firmness of the knee. 

Third or mixed method. — Solingen, according to Camper's account, 
while endeavoring to keep the fragments in apposition, advised occa- 
sional bending of the knee to obviate anchylosis. Bromfeild, with 
still greater prudence, waited for the inflammation to subside before 
he put on any apparatus, and only attempted daily and gradual 
flexion of the joint at the end of the third week. Mr. Benjamin 
Bell, on the contrary, applied the apparatus from the commencement, 
took it off for the purpose of making gentle flexion on the twelfth or 
fourteenth day, replaced it, and renewed the process of bending 

* Warner, Observ. de Chirurgie, [Cases in Surgery, Lond., 1760,] French 
transl. in 12mo., p. 159; Camper, loc. cit.; Flajani, Nuovo methodo di medicare 
alcune malattie, etc. in 4to., Roma, 1786. 



A TREATISE ON FRACTURES. 621 

every two or three days. Finally, Ravaton let the dressing remain 
until the twenty-fifth day, only beginning then to move the joint, and 
taking the important precaution of coaptating the fragments with the 
fingers while the movements were being made. The apparatus, being 
replaced, was again renewed every five days, and not finally left off 
until two months from the time of its first application. 

Which of these three plans is preferable? The second unavoidably 
endangers weakness of the knee and all its consequences ; the third 
is apt to interfere with bony consolidation; the first would certainly 
be the safest, if, on the one hand, it did not tend to cause stiffening 
of the joint, and if, on the other, it insured a closer contact and more 
perfect union of the fragments. 

Now, as we have seen, the stiffening may result from one or more 
of these four causes : (1) the intensity of the inflammation ; (2) the 
application of an apparatus during the inflammatory period; (3) the 
pressure of the apparatus; (4) the too prolonged immobility of the 
joint. By avoiding these causes, we can guard with certainty against 
their result. 

The intensity of the inflammation is due either to the accident 
itself, or to the improper treatment employed. It may readily be 
allayed by rest, position, emollient poultices, and, if necessary, by 
blood-letting. It should be remarked that the elevation of the entire 
limb, which is the best position on account of the fracture, is also 
the most favorable for the resolution of the inflammation. Conse- 
quently, as soon as the surgeon is called to a fracture of the patella, 
he should lay the patient on his back in bed, making with a chair an 
inclined plane reaching from the buttock upward to the heel; upon 
this chair I would put a board six or seven inches in width, covered with 
a thick cloth several times folded, so as to form a kind of mattress for 
the limb, and having a foot-board, to prevent any motion of the foot 
from side to side. The leg is fastened to this board with a folded 
handkerchief, and the thigh with another; the knee is left to be 
covered with poultices, which should be frequently renewed. If from 
the degree of extension there is pain in the ham, this should be sup- 
ported by means of compresses or a small pad; and general treat- 
ment should be adopted according to the grade of the inflammatory 
action. 

It need hardly be said that it would be very imprudent to make 
use of pressure as long as any inflammation remains, and it is even 
well always to allow the first few days to elapse before resorting to any 
other means than position. Bromfeild opposes strongly the premature 
application of apparatus, which often gives rise, says he, to violent 
swelling, sometimes to suppuration, and even to gangrene. Sabatier, 
after at first following this injudicious practice, was so struck with 
its pernicious effects, that he went to the other extreme, and renounced 
the use of apparatuses of every kind. I have myself seen a figure- 



622 A TREATISE ON FRACTURES. 

of-8 bandage, applied on the first day, induce sloughing at the points 
of its greatest pressure; and M. Defer has published a case of gan- 
grene brought on by the premature application of a starched 
bandage. 

I shall not stop to notice undue pressure by the apparatus. But 
the duration of the treatment is of much greater importance. 

Bassuel removed the apparatus by the twenty-fifth day ; Yerduc, 
from the thirtieth to the fortieth ; Sir A. Cooper, on the thirty-fifth 
day in adults, on the forty-second in old persons ; J. L. Petit, on the 
fiftieth ; Boyer, after sixty or seventy days ; and lastly, Dupuy tren 
claims to have been the first to retain the apparatus for three or four 
months. The callus, whether bony or fibrous,, being completed by the 
fortieth day, there is no advantage to be gained by keeping the knee 
any longer immovable; and there is a very serious inconvenience in 
the articular stiffening thus involved. 

Now, by postponing the application of any apparatus until the 
subsidence of the inflammation, and by removing it, according to cir- 
cumstances, from the thirty-fifth to the fortieth day, I have always 
seen the stiffening disappear readily in a short time. Such is there- 
fore the rule which I should lay down, and which I follow. 

But to obtain bony consolidation, it clearly results from w T hat has 
been already said that the apparatuses hitherto employed are insuf- 
ficient. I have therefore devised another, taking its points oVappui 
upon the bone itself without the interposition of the integuments, 
and acting upon the fragments in the same way as the twisted suture 
acts on the soft parts, except in not passing entirely through. 

To make this instrument, take two steel plates, each an inch long 
and two-thirds of an inch wide, sliding upon one another, and this 
sliding regulated by a screw. The free extremity of each is bifur- 
cated, and recurved into two very sharp hooks. The two hooks of 
the lower plate, only one-third of an inch apart, are intended to be 
inserted at the apex of the patella, which is lodged between them ; 
those of the upper plate, which are to catch upon the base of the 
bone, may be separated by a space twice as wide ; and the inner one 
should also be longer than the outer by one-sixth to one-fifth of an 
inch, to make up for the obliquity of this end of the bone. 

The two plates being separate, I begin by passing in the two hooks 
of the lower one just below the point of the patella, only taking care 
to have the skin previously drawn somewhat downward. This done, 
I bring the fragments as nearly as possible into contact by pressure 
with my fingers ; I have the skin covering the upper one drawn up- 
ward, in order that it may not be puckered into unsightly folds by 
catching in the interspace; now, committing the fragments so ap- 
proximated to an assistant, I insert the upper hooks immediately 
above the base of the bone, until their points^bear upon it as & point 
oVappui. Great force must be employed here, to pass in the points 



A TREATISE ON FRACTURES. 623 

as deeply as possible; I have satisfied myself by numerous experi- 
ments that it is impossible to go entirely through the tendon, and 
that there is much more reason to apprehend taking hold too superfi- 
cially. The lower hooks pass completely under the edge of the pa- 
tella, which is very thin at its apex, embracing this edge in their 
curve, and always becoming firmly fixed; but the upper ones have 
no purchase except upon the sloping surface at the base of the bone, 
against which they must be strongly pressed until the screw is sub- 
stituted for the fingers, or they will slip. 

The four hooks being properly placed, we approximate the two 
plates by sliding them upon one another, forcing them together by 
means of the screw. At first I made use of a simple adjusting screw, 
which, although very simple, I soon found to involve two disad- 
vantages: first, the screw was left at the disposal of the patient; 
secondly, its working up or down required some force, and this gave 
the whole apparatus a twist, causing the patient much pain. M. Char- 
riere provided each plate with an upright, bored horizontally for a 
screw, which of course plays parallel to the plates themselves, and 
may be worked by a key as in winding up a watch; and in this way 
the inconveniences mentioned are entirely done away with. 

I have so far applied this apparatus in four instances, three of 
which were recent fractures. In the first, the hooks were inserted 
on the fifteenth day and left in place twenty-two days ; I then per- 
ceived that the upper pair had slipped, tearing the skin; the whole 
thing was therefore taken off. The fragments remained separated 
by three or four millimetres; but their union was so firm that they 
did not move upon one another ; flexion was entirely restored ; the 
patient recovered his strength completely. To give some idea of this, 
he came to see me some months afterwards, having walked sixteen 
miles in nine hours, and expecting to walk six more to finish his 
day's journey. 

The second case was that of a boy eleven years old; the hooks 
were inserted on the fourteenth day, and kept in place for an entire 
month. The result was as successful as possible; the fragments 
were completely united by bone, as far as could be made out in the 
living subject, and the knee regained its original mobility and 
strength. 

In a third case, the hooks were inserted on the fourth day, began 
to slip on the twenty-first, and on the twenty-seventh were re- 
moved. ~Xt the outer side the fragments were firmly united, pro- 
bably by bone; but internally there was some little separation. 

Lastly, in a patient who had had for three months a transverse 
fracture, still ununited, and whose knee was extremely feeble, I at- 
tempted the application of the hooks, and kept them on for forty-one 
days; at first the fragments seemed pretty well consolidated, but in 
two days the separation was as wide as ever. 



024 A TREATISE ON FRACTURES. 

From the former of these cases we see how much success may be 
looked for in the judicious employment of this apparatus. Experi- 
ment has shown me at the same time two facts, equally unexpected; 
on the one hand the difficulty of adjusting the hooks, and on the 
other, their astonishing harmlessness when thrust through the tissues. 

When I made my first attempt, I anticipated inflammation, sup- 
puration, and perhaps a little necrosis, and did not calculate upon 
leaving the apparatus in place for more than ten days. I was hap- 
pily surprised at meeting with nothing of the kind ; there is not even 
any redness around the hooks, as long as they do not slip ; and on 
their removal, cicatrisation ensues in two or three days. 

But on the other hand, it is very difficult to fix the upper hooks 
firmly. M. Robert tried my plan at the HopitalBeaujon ; he could not 
approximate the fragments; and the patient dying from visceral dis- 
ease, the autopsy showed that instead of catching upon the base of 
the bone, the upper hooks bore upon its anterior face, their points 
being engaged in the fibrous layer covering it. In my own attempts, 
when the accuracy of the coaptation showed that the application was 
properly made, it has been seen that the upper hooks were liable to 
slip at about the seventeenth to the twenty-second day. This is 
because they do not, as might be supposed, penetrate the substance 
of the bone ; they are arrested, however great force we may employ, 
at its surface; and if this surface is sloping, like the base of the 
patella, they are only held by the tendinous fibres through which 
they have passed. After a certain period, these fibres become in- 
flamed and softened by the pressure they sustain ; and hence there 
occurs a slipping which makes it necessary to tighten the screw, or, 
if renewed, requires the removal of the whole apparatus. I have not 
hitherto succeeded in obviating this inconvenience, which is unat- 
tended with any risk, only affecting the exactness of the coaptation 
of the fragments and the closeness of their union. 

Such is therefore my practice in all cases of transverse fractures 
with somewhat marked separation. When the separation is slight, 
sometimes mere position may suffice, with the addition of emollient 
poultices to allay irritation and muscular spasm. I have communi- 
cated to the Societe de Chirurgie the case of a man cured in this 
manner, with bony union, of a direct fracture in which the separa- 
tion had not been more than two millimetres. So also when the 
hooks have had to be prematurely withdrawn, rest, position, poul- 
tices, are still the surest means for completing the cure ; in one case 
I tried substituting pressure for the hooks, but the little wounds be- 
came inflamed, and erysipelas -supervened. 

I shall not dwell upon the course to be pursued during convales- 
cence; it is the same as in fractures generally. We should however 
make gentle but persevering attempts to restore as soon as possible 
the complete flexibility of the knee. 



A TREATISE ON FRACTURES. 625 

* 

But we are not always called in in time, and I have been several 
times consulted by persons who in consequence of the laxity of the 
uniting band felt the knee give way under them in walking. Sir 
Charles Bell recommends that in all cases, in order to obviate the 
danger of falling, patients should be dismissed with a firm splint at 
the back of the joint, so as to prevent any yielding of the knee.* 
John Hunter was consulted by a lady, who in consequence of a 
fracture of the patella which had been left to itself, had lost the use 
of the limb, and could only move about by means of a wheel-chair. 
He advised her to move the leg frequently, by the force of her will 
aided by that of her hands. In three or four months the extensor 
muscles regained their action, and the patient could walk without 
any assistance. Sir A. Cooper succeeded in the same way with a 
woman who in consequence of breaking both patella) had lost the 
free use of both legs. 

Here then are two very different lines of practice. It seems to 
me that we give them their true position in regard to one another, by 
saying that in the cases treated by Hunter and Sir Astley Cooper 
there must have been a necessity, after the cure was complete, for 
the posterior splint of Sir C. Bell. But some surgeons, with greater 
boldness, have, conceived the idea of freshening up the fractured 
surfaces, and then bringing them together again. 

Severinus proposed, in a case of this kind, to lay bare the frag- 
ments by an incision, and then to make a new surface to each; which 
plan was fortunately not carried into execution. f But it is said that 
Dieffenbach, some years since, made a subcutaneous section first of 
the ligamentum patellae, and afterwards of the tendon of the rectus 
femoris three inches above the joint, so as to avoid the synovial 
cavity; after which, having rubbed the fragments together, he kept 
them in contact by means of an apparatus for parallel pressure, and 
obtained a new union with very marked impovemcnt.J I doubt the 
accuracy of these details. In the first place the section of the rectus 
femoris tendon would be quite useless unless the other portions of 
the quadriceps extensor were divided also; secondly, the perform- 
ance of section of the ligament, in addition to that of the muscles, 
is incomprehensible; thirdly, these two sections would give rise to 
infirmity quite as troublesome as that from a badly united fracture ; 
in a word, I should consider such an operation wholly unjustifiable. 
I once attempted for forty days, as was before stated, to bring to- 
gether the fragments in a fracture of three months' standing, without 
any satisfactory result. Perhaps it would have been proper here to 
freshen up the surface- with ;i tenotome introduced subcutaneously, 
before endeavoring to make the coaptation. Apart from this last 

* London Medical Gazette, 1827, vol. i, p. 25. 

i II . A. Beverinos, Chirwrgice ejficacis, partii, cap. vii. 

X Gazette Medicate, 1841, p. 78U. 

40 



626 A TREATISE ON FRACTURES. 

resource, the simplest and surest plan is to make the knee immovable 
by means of a hollow splint beneath the ham. 

If walking is interfered with by extreme stiffening, giving pain 
upon the slightest motion, I should advise a resort to a similar splint. 



§ II. — Vertical [Longitudinal] Fractures of the Patella. 

Fractures of this form are the rarest of all ; but I allude to them 
here because their examination will aid us in studying the multiple 
variety. 

Guillaume de Salicet was the first to mention them ; but we must 
come down to Van der Wiel and Delamotte to find instances quoted;* 
and Sir A. Cooper and Dupuytren are the only surgeons who have 
given special attention to the subject. 

These injuries are caused by falls on the knee, or by direct vio- 
lence acting on the patella. Dupuytren saw one which was due to 
the passage of a carriage- wheel over the knee; Couste', one produced 
by a splinter from a gun-carriage striking the patella of an artil- 
leryman, f 

They present several varieties. In the first place, some fractures 
which are properly oblique are called vertical, as may be seen in Sir 
A. Cooper's plates. Again, they are distinguished according as the 
bone is divided into two nearly equal portions, or only one-third or 
even one-fourth is separated. We find in Daniel Turner's work the 
history of a much more remarkable form, if the diagnosis were only 
more clearly made out ; a girl thirteen years old struck her knee 
against a door, and sustained a considerable contusion ; an abscess 
supervened, and a portion of the patella came away, which was re- 
garded by three surgeons as having been detached by a fracture. 
This fracture had divided the bone nearly vertically, but from side to 
side, without entering the joint; this case is hitherto unique, but the 
meagreness of the essential details unfortunately leaves room for 
doubt whether it was not merely a case of necrosis. { 

Lastly, Sir A. Cooper states that in 1822 there was dissected at 
St. Thomas's Hospital the body of a man, who had a vertical frac- 
ture of each patella. 

Besides contusion, pain, swelling, and all the general symptoms, 
the distinguishing feature of these fractures is the lateral separation 
of the fragments. In Van der Wiel's patient this was sufficient to 
allow of the introduction of the little finger ; in Delamotte's it was 
two good fingers'-breadths wide. It may be seen to increase when 

* Stalpart Tan der Wiel, Observat. rariores, 1687, obs. 97 ; Delamotte, op. 
cit., obs. 366. 

1 Couste, TJi&se tnaug., Paris, 1803, No. 22. 

X Turner, Art of Surgery, fifth ed., vol. ii, p. 273. 



A TREATISE ON FRACTURES. 627 

flexion of the knee is attempted ; it is diminished in extension, and 
the two fragments may be brought in contact and rubbed together so 
as to elicit crepitation. 

This singular separation has been a matter of surprise to surgeons. 
Dupuytren declares that the muscles have no tendency to produce it; 
Sir A. Cooper thinks that they rather lessen it; and from some ex- 
periments on rabbits, he infers that it is the condyles of the femur 
which when the knee is flexed press the fragments away from one 
another. But besides that this theory could hardly be sustained in 
regard to man, extension, even when most complete, still leaves the 
fragments separated. Sir Astley's last experiment especially should 
have undeceived him. Having divided the patella crucially, the two 
lower fragments were not displaced, and united by bone ; the two 
upper ones remained apart, and became connected only by fibrous 
tissue. 

I think that here we must recognise muscular action. If we study 
this region in man, we find the fibres of the vastus externus, running 
very obliquely as compared with those of the rectus, going to be in- 
serted by a common tendon into a special facette at the outer angle 
of the patella; the fibres of the vastus internus, less oblique indeed, 
are attached to the whole inner edge of that bone, even reaching as 
far down as the tibia. But if the patella be divided into two lateral 
portions, these will be drawn apart by the action of these powerful 
fasciculi, which antagonise one another ; which shows why the sepa- 
ration is greater the more these muscles are stretched, as in flexion 
of the leg ; why it still exists in extension, unless the preservation 
of the fibrous tissues interferes directly with the traction of the 
muscles ; and why, lastly, when the fracture is cruciform, the two 
upper fragments are still drawn apart, while the lower ones are not 
separated, but drawn aside together if the vastus internus continues 
to act, the vastus externus having lost all its power over the outer 
one. 

There is therefore here, as in the transverse variety, a muscular 
contraction holding the fragments apart, and thus tending to prevent 
bony union ; so that, in all cases in which the state of things has 
been investigated by dissection, the callus has been fibrous. It may 
easily be seen that if the fibrous tissues covering the bone escape 
division, the fragments will be held together, and will unite by solid 
ossific deposit; and this Sir Astley Cooper verified by special experi- 
ment. 

The prognosis should therefore be to a certain degree reserved ; 
but it does not appear that the fibrous character of the union need 
impair the function.- of the limb at all. 

The treatment reduces itself to this one grand indication, to oppose 
the action of the muscles, in order to approximate the two fragments. 
The leg should consequently be put in complete extension, but it is 



628 A TREATISE ON FRACTURES. 

not worth while to elevate the heel, since the rectus muscle exerts no 
unfavorable influence on this fracture. The inflammation being sub- 
dued, it will be well to employ some apparatus for making pressure, 
in addition to mere position ; Sir A. Cooper advises putting at each 
side of the patella a pad, and bringing the two together by means of 
a laced knee-cap and two straps, one above and the other below. 
Perhaps this apparatus is rather complicated, and the same end 
would be as surely attained by laying two simple graduated com- 
presses along each side of the bone, and drawing them together by 
strips of lead-plaster. 



§ III. — Multiple Fractures of the Patella. 

After what has been said in the two foregoing sections, but little 
need be said to complete the history of multiple fractures. 

These are always due to a fall on the knee, or to a direct blow. 
Most commonly they are double, the upper fragment of a transverse 
fracture being divided; I have recently seen a case of this kind. 
Sir Charles Bell met with another form, consisting in a longitudinal 
fracture near the inner edge of the bone, the outer fragment being 
in its turn divided across. I have reported an instance of two trans- 
verse fractures of the same patella, but not produced at the same 
time. More numerous fractures are rare ; thus I know of no exam- 
ple of a triple division of the bone. Sir C. Bell has had represented 
a patella broken into five pieces ; a still more comminuted fracture 
may be found in Fig. 83 ; and these are the only instances I can 
cite. 

Ecchymosis is in these cases very common, and the swelling is 
generally considerable. Still, probably by reason of the soundness 
of the fibrous envelope, the separation is apt to be less than in trans- 
verse fractures ; and Camper, Sir Charles Bell, and Gulliver have 
shown that bony consolidation is also more frequent. Facts observed 
only during life are, it is true, of but little value ; but autopsies are 
not wanting ; Sir Charles Bell states that he examined four patella 
fractured by direct violence, in which osseous union had occurred in 
various degrees ; and he showed at his lectures the one spoken of as 
broken into five pieces, agglutinated and held together by masses of 
coagulable lymph, which was already ossified at several points. In 
#11 these cases the inner surface was sound, except that the cartilage 
was divided ; the callus gave rise to irregularities only on the ante- 
rior face of the bone, which in the specimen last mentioned, for in- 
stance, showed masses of lymph and ossific deposit like those met 
with in fractures of long bones. 

These fractures are recognised either by the mobility of the frag- 



A TREATISE OX FRACTURES. 629 

incuts, or by their separation, rendered evident by the increased 
width of the bone. 

In double fractures, with three fragments, if the vertical division 
is seated in the upper portion, we must look for some separation by 
muscular action, which however will not interfere with the functions 
of the limb. It would seem, on the contrary, that no separation 
attends vertical division of the lower fragment. 

As to the treatment, we must pay attention mainly to the trans- 
verse fracture, taking care also that the separation in the other does 
not become excessive ; if the fragments remain in contact, we need 
only insure the proper position of the limb, moderating the inflam- 
mation if necessary. 



CHAPTER XVIII. 

FRACTURES OF THE BOXES OF THE LEG. 

Of all fractures, these are the most common ; including those in- 
volving both bones and those involving only one, they constitute 652 
out of our whole number of 2328 single fractures, while among the 
thirty patients with multiple fractures, the leg was broken in twenty- 
six. According to this, they form more than one-quarter of all the 
fractures met with in practice. 

We distinguish first, fractures of both bones, — fractures of the leg, 
properly speaking; fractures of the tibia; and fractures of the fibula. 
We shall study separately fractures just above the malleoli, and those 
seated at the malleoli. 

Fractures involving both bones are the most frequent ; then come 
those of the fibula, and lastly those of the tibia. Of the first there 
are found in my summary 515 ; of the second 108 ; of the third 
only twenty-nine. I cannot say that these figures express the exact 
relative frequency of the varieties ; thus under the head of fractures 
of the leg there may have been placed some fractures of the tibia 
alone ; and certainly the estimate is too low as regards fractures of 
the fibula. But I shall refer to this question again hereafter. 



§ I. — Fractures of the Leg. 

These are very rare in early infancy; of the 515 cases, but one 
was as young as four years. From five to fifteen, there are only 
twelve ; so that there seems to be during childhood a sort of antago- 
nism between fractures of the leg and those of the thigh. 

The number increases rapidly after the fifteenth year; from that 
to the twenty-fifth, for example, we find fifty-seven. From twenty- 
five to thirty-five years the number nearly doubles, and holds its 
own after that until about the age of sixty. Between sixty and 
seventy it falls to sixty-one ; from seventy to eighty we find only 
twenty-two, and there are only four in persons over eighty. 

Men would appear to be twice as liable to this accident as wo- 
men: 344 to 171. But this proportion is by no means the same at 
(630) 



A TREATISE ON FRACTURES. 631 

all periods of life. Thus from infancy to fifty years of age, there 
are 234 males to 74 females, — three to one. From fifty to seventy- 
five, the two sexes approach one another remarkably, — there are 
only ninry-seven men to eighty-six women. Lastly, beyond seventy- 
five years, the women notably exceed the men — being as eight to 
three. 

The influence of cold weather is quite marked; the summer sea- 
son affords but 201 fractures, while 314 occurred during the winter. 

The determining causes are direct or indirect. The former are 
perhaps a little more frequent than the latter; I have traced them 
in thirty-six cases out of sixty-seven. Sometimes a carriage-wheel 
passes over the limb; sometimes a heavy body, such as a mass of 
building materials, a beam, a falling bank of earth, etc.,. may come 
down upon the leg from a variable height; or perhaps a violent blow, 
such as the kick of a horse, is received while the patient is standing 
up. and the fall is consecutive to the fracture. 

Among the indirect causes, the most common seems to be a simple 
fall on the pavement, from a false step; of my thirty-one instances 
of indirect fracture, ten were so produced. If to these falls are 
added those sustained in running, or in struggling, whether the pa- 
tient slips, or a stick is thrust between the legs, or the foot is twisted 
in a rut, we have a proportion of eighteen out of thirty-one, due to 
falls from the erect position. The rest are owing to falling from 
greater heights, as down a staircase, from a ladder, a scaffolding, or 
a roof, etc. In one unique case, the patient was falling from a lad- 
der, when his leg caught between two of the rounds, and was thus 
broken by an altogether peculiar mechanism. 

In studying the influence of these causes upon the seat of the 
injury, I have arrived at quite curious results. Among my thirty- 
six direct fractures, the exact locality is omitted in one; eighteen 
were in the middle portion of the leg ; two only were higher up, near 
the knee; six at about the lower third; eight somewhat lower down, 
an inch or two above the malleoli; and one was double, affecting the 
upper as well as the lower third. Does not this very large propor- 
tion of fractures at about the middle of the leg authorise the pre- 
sumption that some of them were the result of counter-stroke, and 
seated at a different point from that at which the blow fell? It 
would be hard indeed to conceive that carriage-wheels should so 
often pass exactly over the middle of the leg. 

Indirect fractures seem to choose a very different seat. Of my 
thirty- . in one the exact point is not designated; in twenty- 

one, the tibia was broken somewhere in its lower fourth, more or less 
close to the malleoli; in three, in its lower third, and in six at its 
middle. 

According to these Bgures, fractures of the upper third, which 
are vciy nearly the rarest of all, would be due solely to direct causes; 



632 A TREATISE ON FRACTURES. 

those about the middle, of much more frequent occurrence, would 
find their principal causes in blows or great. pressures; and lastly 
those in the lower third, the most common of all, should be ascribed 
more especially to indirect violence. There is thus a remarkable 
analogy between fractures of the lower extremity of the leg from 
falls on the feet, and those of the lower extremity of the radius 
from falls on the hand. 

Each order of causes is attended also by complications, more or 
less numerous. Of my thirty-one indirect fractures, only nine com- 
municated by wounds with the external air, while of thirty-six from 
direct violence, eighteen presented such a communication. In the 
latter the wound is due to the external violence, and takes place 
generally from without inward; in the former, on the contrary, it is 
ordinarily one of the fragments of the tibia, and almost always the 
upper one, which pierces the integuments from within outward. 
The height of the fall has something to do with this disastrous com- 
plication, but we should not ascribe to this an undue influence. 
Three men, who had fallen upon their feet from a height of twenty- 
five or thirty feet, had fractures without any external wound ; four 
others, from simple falls upon the ground, sustained. compound frac- 
tures of such gravity, that two of them died. 

Besides the differences resulting from their causes, seat and com- 
plications, fractures of the leg vary also according to the disposition 
of the fragments. In the first place, it is quite rare for the two 
bones to give way at the same level ; this only occurs in fractures 
from direct violence, and even in these the fibula is often broken 
either higher up or lower down than the tibia, or in both points at 
once. As for indirect fractures, in them the seat of injury in the 
fibula is almost always two or three inches above that in the tibia. 

I have elsewhere (page 67) mentioned how some surgeons may 
have been misled in regard to the occurrence in the tibia of fractures 
en rave, and it is unnecessary to repeat what was there stated. 
Fractures of the leg present themselves therefore as serrated, oblique, 
splintered, comminuted and multiple; and the same remarks apply 
to either bone; only that as the tibia is the more superficial and the 
larger of the two, our observations are directed almost entirely to it. 

Oblique fractures of the tibia vary much in the degree of their 
obliquity. Some divide the bone in a direction nearly transverse; 
others are almost longitudinal, and the fragments are sharpened, as 
the expression is, into a very long bee de flute. In general the line 
of fracture runs downward and inward, (see Figs. 88, 89, 90 ;) often 
also it passes downward and forward, {Fig. 86;) very rarely it takes 
the opposite directions ; I have however represented in Fig. 87, a frac- 
ture running from above downward and backward; and there have 
been seen fractures which were oblique downward and outward. It 
must be added that these expressions are only approximative; that 



A TREATISE ON FRACTURES. 633 

o 

the most marked obliquity in any one direction almost always en- 
croaches more or less upon some other face of the bone; and that, 
strictly speaking, the most common of all forms of oblique fracture 
is that which runs downward, inward and somewhat forward. 

Splintered fractures present far more numerous varieties of form. 
The most usual is that already spoken of, (page 73,) an example of 
which may be seen in Fig. 7. Here we see a wedge-shaped piece 
detached from the outer face and anterior edge of the bone, and 
squeezed out toward the fibula by the approximation of the two 
fragments from which it has been separated. I have more than once 
observed in the living subject such a splinter, displaced in this way, 
remain prominent and movable in the interosseous space, even after 
the two portions of the tibia were united by solid callus. I would 
also call attention to a form of splinter peculiar to very oblique 
fractures of the tibia ; its line of division runs parallel to that of the 
main fracture, for a distance of two or three inches or more; and it 
often gives rise to suppuration which can only be checked by its 
extraction. 

The general symptoms of fracture, contusion, swelling, pain, mo- 
bility, crepitation, etc., are here present in a very marked degree, 
and the diagnosis is rarely obscure or uncertain. There is besides 
commonly more or less displacement, rendering the nature of the 
case perfectly evident. Still, in those rare instances in which the 
fragments remain interlocked, or in which an obstacle to angular 
deformity is presented by the difference of level of the points of 
division of the two bones, there occurs a very remarkable pheno- 
menon, which of itself would suffice to attract the surgeon's atten- 
tion; this is starting of the limb, taking place at intervals through 
the night, and violent enough to awaken the patient. From this one 
symptom I should not hesitate to infer the probability of one of the 
bones at least being broken, more especially the tibia, and to adopt 
all the means necessary to place it beyond doubt. 

Fractures of the leg are subject to all the varieties of displace- 
ment. In the first place they may be transverse, or in the direction 
of the thickness of the bone, rarely complete as regards the tibia, 
almost always so in the fibula in case of overlapping; generally it is 
the upper fragment of the tibia which is carried forward and inward. 
Then comes angular displacement, occurring at the outset from the 
fracturing cause, from the weight of the limb, in a w r ord, from some 
external agency; and subsequently kept up or even increased by 
muscular action. It is chiefly the muscles of the calf, acting on the 
calcaneum, and by it on the lower end of the lower fragment, by 
which this hitter is drawn backward, so as to form with the upper 
one an angle more or less salient anteriorly. I have seen k case of 
this kind in which union had taken place with the two fragments at 
a right angle ; in another, an account of which is given by M. Josse 



634 A TREATISE ON FRACTURES. 

o 

of Amiens, the angle was an acute one.* Different conditions of the 
fracture may affect the direction of this angle ; for instance, in frac- 
tures just above the malleoli, which will be examined separately, it 
is more commonly salient inward than outward. 

Displacement by rotation, or in the direction of the circumference, 
may be due to the external violence, or perhaps to eversion or inver- 
sion of the foot by its own weight; but usually it results from unin- 
tentional movements of the patient, or from the pressure of the bed- 
clothes. 

Overlapping is hardly met with except in oblique fractures, in 
which it is almost constant. Sometimes it is produced in an inordi- 
nate degree by the fracturing cause; as in falls from heights upon 
the feet, the upper fragment of the tibia has been seen to penetrate 
the muscles and skin, and even to bury itself in the ground. In 
other instances, the force being less, it merely projects under the 
skin, distending and threatening to rupture it; but generally the 
overlapping is very limited, the thickness of the tibia scarcely allow- 
ing the fragments to completely abandon one another, the interosse- 
ous ligament serving also as a check if necessary, and lastly, perhaps 
from the fact that most of the muscles of the leg are attached along 
the entire length of both bones. 

But there is one other form of displacement, hitherto confounded 
with transverse displacement or with overlapping, and deserving of 
special attention, namely, the separation of the fragments. I have 
just said that in some cases of overlapping, the point of the upper 
fragment stretches the integuments and threatens to pierce them; 
and indeed, by glancing at most of the drawings from No. 85 to No. 
90, we see that the lower fragment in a case of oblique fracture can- 
not go up along the upper one, without forcing the latter either to 
one side or the other. But besides this mechanism, which is due to 
the muscles of the leg, there is another agency drawing the upper 
fragment directly away from the lower, and making its point project 
forward ; this is the contraction of the muscles inserted into the pa- 
tella. In fact, if the muscles of the leg alone are acting, the pro- 
jection forward of the upper fragment may be overcome by position, 
and especially by permanent extension. Now if we try flexing the 
limb with the view of relaxing the muscles, the prominence increases; 
if we make sufficient traction to obviate the overlapping, the promi- 
nence diminishes, but does not entirely disappear; on the contrary, 
it is in all cases diminished, and in some completely effaced, if to a 
sufficient degree of extension is added strong pressure over the salient 
point; and the influence of such pressure is so marked, that no 
doubt can remain as to the action of a force tending to raise the 
fragment in question, and to separate it from the lower one. 

* Journal de CTiirurgie, Oct., 1846. 



A TREATISE ON FRACTURES. 635 

The course of fractures of the leg is very simple, when there is 
no displacement, or when the displacement, transverse or rotary, is 
but slight, even though there may be overlapping. The callus forms 
in thirty-five or forty days; and we may take off the apparatus and 
let the patient move his limb in bed without any inconvenience re- 
sulting. But it is otherwise with oblique fractures, when the upper 
fragment projects. Even when this fragment does not threaten to 
pierce the skin, the separation of the broken ends presents the same 
obstacle to consolidation, in a different degree, which is met with in 
fractures of the patella. If we take off, at the end of forty days, 
any ordinary apparatus, the patient cannot move the limb without 
experiencing at the seat of injury pains, which almost certainly indi- 
cate that consolidation is imperfect; and in two or three days after- 
wards, the mobility will often reappear; in one of my patients, who. 
had been eighty-four days in the hospital, the callus gave way seve- 
ral weeks later, from a very slight movement. 

Dupuytren was struck with the weakness of the callus in these 
cases of oblique fracture; besides the pains, mobility, and deformity, 
and the pseudarthrosis so common after fractures of this kind, he 
pointed out a consecutive shortening of the limb, which he ascribed 
to yielding of the callus under muscular contraction. Hence, judg- 
ing that the definitive callus alone was capable of resisting this force, 
he came to the practical conclusion that in oblique fractures it was 
necessary to keep on the apparatus for three months.* 

I have stated already (page 126) my views as to this theory. 
There is no provisional callus here, any more than elsewhere; when 
the limb becomes shortened, it is because bony union has not occurred ; 
and it is not only the muscles, but the weight of the limb, and espe- 
cially that of the body in walking, by which the immature callus is 
strained, and loses its firmness. By exerting sufficient pressure on 
the separated fragments, however oblique, I have more than once 
obtained perfect consolidation in less than forty days. 

Splintered and comminuted fractures are subject to the same risks, 
and from the very same cause. They eventually unite, but with 
stiffening of the neighboring joints in proportion to the length of the 
treatment, and nearly always with deformity; while if we try to 
shorten the period, we endanger the formation of a false joint. If, 
on the contrary, the fragments have no tendency to separate, consoli- 
dation occurs without difficulty, but never so rapidly as in single 
and serrated fractures. 

I shall not dwell here upon the course of compound fracture?, but 

refer the reader to the general discussion of that subject. Only, 

the great obstacle to union here is still the mobility and especially 

paration of the fragments; so that if we can succeed in fixing 

second edition, tome i. p. 36. 



636 A TREATISE ON FRACTURES. 

them by suitable pressure, we may obtain almost as speedy a cure as 
in a simple fracture. 

The method of consolidation presents nothing special, when the 
fragments have remained or are replaced in contact; each of the 
fractures unites by itself, and the bones are restored to their usual 
condition. But when one of the fragments of the tibia is carried 
toward the fibula, or the reverse, osseous deposits take place so as to 
connect one bone with the other, sometimes at one point only, some- 
times at two or three; and by these the play of the tibio-fibular arti- 
culations is manifestly destroyed. (See Figs. 88, 89, and 90.) In one 
specimen in theJVlusde Dupuytren (No. 135) the two bones are sol- 
dered together at the level of the fracture, and as a consequence 
complete anchylosis has occurred at their lower junction. 

The diagnosis may generally be made out with the greatest ease, 
especially in regard to the fracture of the tibia. That of the fibula 
is detected most commonly by the mobility and displacement of the 
tibia, rather than by any symptoms of its own; and it is but rarely 
that we can recognise its precise seat, or the arrangement of its 
fragments. This, however, is of but very slight consequence. 

The prognosis is very simple unless there is displacement. But 
when the fracture is oblique, or comminuted, and gives rise to a per- 
sistent prominence, the prognosis rests essentially upon the plan of 
treatment adopted; and a patient may remain crippled, or even lose 
his life, from a badly managed fracture, which a more enlightened 
surgeon would have cured as readily as any ordinary case. 

In order to accomplish reduction, when no very great power is re- 
quired, an assistant holds the knee, grasping it with both his hands; 
another takes the heel between the thumb and fingers of his left 
hand, and puts the four fingers of his right hand over the metatar- 
sus, the thumb coming under the sole, so as to pull on the foot, keep- 
ing it at a right angle with the leg; care should also be taken to 
have the inner edge of the great toe in the same vertical plane with 
that of the patella. When two assistants are insufficient, a handker- 
chief should be tied below the knee, or even a loop passed around 
the groin of the injured side, to make counter-extension, and a hand- 
kerchief made into a cravat tied around the foot to make extension; 
the two ends of this may be drawn upon by any number of assist- 
ants that may be requisite. The mode of applying it is not unim- 
portant. When there is only a simple lateral displacement, its middle 
portion is passed beneath the tendo-Achillis, and its ends are crossed 
over the instep; but if the fragments present an angle anteriorly, 
such an arrangement would only increase the deformity. We then 
simply shift the centre of the cravat to the front, tying the ends 
behind in a single knot ; traction made upon these will have the effect 
of elevating the heel, and depressing, by a kind of lever movement, 
the lower fragment. But the best way to fasten the cravat is to 



A TREATISE ON FRACTURES. 637 

make one knot opposite one malleolus, and then carrying one end 
under the tendo-Achillis, to make a second knot on the other side; 
we thus form two lateral loops, by means of which traction may be 
made almost exactly in the line of the axis of the limb. 

I have elsewhere described, in a general way, the method of mak- 
ing coaptation ; only the surgeon should recollect that it is not always 
so easy as it is said to be to reduce transverse displacements, even 
when very slight. 

"When there is no displacement, or when the displacement has been 
reduced and does not tend to reappear, we may make use almost 
indifferently of any contrivance, splints, boards, cushions, immovable 
apparatus, etc. It is well, however, to remember that by the incli- 
nation of the foot the lower fragment may be rotated outward ; that 
the weight of the lower portion of the limb, aided sometimes by the 
pressure of the bedclothes, may cause the heel to sink into the 
cushions, making the fragments form an angle salient anteriorly; 
lastly, that the most perfect reduction of a fracture cannot prevent 
its derangement by untoward movements of the patient. It is there- 
fore necessary, whatever apparatus may be employed, that the foot 
should be kept at a right angle with the leg, and free from any late- 
ral deviation ; that the surface supporting the limb should be suffi- 
ciently firm ; and that suitable pressure should be made at each side 
to maintain reduction in spite of any slight inadvertence of the pa- 
tient. It may be added, finally, that a slight degree of flexion of 
the knee is more comfortable, as well as more favorable to the relax- 
ation of the muscles and the suppleness of the articulations. 

The immovable apparatus fulfils perfectly all these conditions, and 
presents but one disadvantage, namely, that it conceals the parts, 
and deprives them of the benefit of exposure to air and light. This 
evil is done away with by M. Seutin's plan of dividing it, and on the 
whole, in patients of good constitution, when all danger of inflamma- 
tion is past, I make use of it without hesitation ; in young children I 
prefer it to any other. But except under these circumstances, I con- 
sider it safer to employ splints, which leave the fracture open to ob- 
servation, while retaining it in position. The limb being then placed 
upon a double inclined plane, or the leg alone supported upon cush- 
ions arranged on a firm board, I pass under it a splint-cloth as wide 
as from the knee to the heel ; in this is rolled on each side a broad 
firm splint reaching a couple of inches beyond it above and below. 
Two stuffed bags [junk-bags] of the same length are laid along the 
leg, one on each side, to moderate the pressure of the splints, which 
are held in place by means of three bands. Finally, a short strip of 
bandage surrounds the sole of the foot, its ends crossing one another 
over the instep, and going to be fastened with pins to the splint-cloth. 
By this method the whole anterior portion of the leg is left open, 
ready if necessary for the application of poultices; and if the appa- 



038 A TREATISE ON FRACTURES. 

ratus becomes loose, we have only to tighten up the bands, without 
deranging anything or moving the limb: 

When there is transverse displacement, it is necessary to act upon 
the fragments by pressing them into position, or at least to prevent 
their further derangement. The splints answer this purpose exactly ; 
we may increase the thickness of the padding at some points, and 
diminish it at others, or we may apply immediate splints beneath the 
principal ones. Advantage may also be derived from the employ- 
ment of a cravat placed around the limb at the point of projection, 
and tied over the splint on the opposite side ; but care should be taken 
lest this compression should cause mortification of the integuments. 

Angular displacement may be treated in the same way, but with 
the same precautions. When the fragments incline backward, which 
is rare, we may endeavor to raise them by lowering the heel; in 
place of keeping the foot at a right angle with the leg, we should 
press upon the instep by means of a cravat, previously passed beneath 
the malleoli. On the contrary, when the angle is salient anteriorly, 
the heel and toe should both be kept well up ; the flexion of the knee 
should be increased ; compression should be made in front of the leg 
by means of a pad and splint, or with a cravat tied under the sus- 
taining board; and we may likewise try permanent extension. These 
plans may be variously combined, or they may all be employed at 
the same time, before resorting to more powerful means. 

[In the Pennsylvania Hospital, the great majority of fractures of 
the leg are treated by means of the fracture-box. This may be of 
any size to suit that of the limb affected. It is formed of a bottom- 
piece, reaching from the ham to below the heel; a vertical foot-board 
of sufficient height to prevent the weight of the bedclothes from 
bearing upon the toes ; and two sides hinged to the bottom-piece. 
The foot-board is provided near each lateral edge with a mortise, 
three or four inches long and half an inch wide. In order to use this 
apparatus, three strips of rather wide bandage, and a soft pillow of 
a square form, are required. Two of the strips are laid on the bed, 
a few inches apart ; across them is placed the fracture-box, with its 
sides turned down, and the pillow upon it. The third strip being 
applied by its middle over the tendo-Achillis, and its two ends crossed 
over the instep, the limb is laid in proper position upon the pillow. 
The two ends of the third strip are passed through the mortises, and 
tied on the outer surface of the foot-board, so as to keep the foot 
upright against the latter. Now the sides of the box being brought 
up, the pillow may be so arranged by pressure as to exactly fill up 
the interspaces between the limb and the box, and the "whole is com- 
pleted by tying the first-mentioned strips so as to keep the sides up 
as closely as may be required. Any points especially exposed to 
pressure may be protected by lint or raw cotton, or compresses may 
be employed if the pillow does not bear sufficiently upon any part of 
the limb. 



A TREATISE ON FRACTURES. 639 

A box of tins kind may be put together in a very short time; and 
there is nothing equal to it when a patient with a fractured leg is to 
be moved from one place to another. In such cases the hinges, al- 
though convenient, are not indispensable ; so that the only really- 
necessary materials are the boards and nails; straw may be arranged 
so as to answer instead of a pillow, and wisps of straw may in case 
of need be used instead of the confining strips of bandage.] 

Permanent extension is applicable also in cases of overlapping; 
but as this is generally very slight, it suffices for the most part to 
fasten the foot to the foot-board of the inclined plane, while a loop 
in the groin connects the body with the head of the bed. If the 
overlapping is more marked, we may take our choice among the me- 
thods of extension described in the chapter on general treatment. I 
shall, however, mention one plan recently proposed by M. de Saint- 
Martin, which is both simple and convenient. 

His apparatus consists of two splints, of a length somewhat ex- 
ceeding that of the leg, unconnected at their upper extremity, but 
fastened below to a cross-piece keeping them at a proper distance 
apart ; holes are bored in this cross-piece at each side, for the pas- 
sage of the extending loops, and in its centre another one for a 
wooden screw, which should play freely. The thread of this screw 
fits a hole in another cross-piece, unattached, and moved toward or 
away from the first one by turning the screw. To afford a point 
d'appui to the upper ends of the splints, a knee-cap of ticking is 
fitted on, having at each side a socket ; into these sockets the ends 
of the splints are inserted. A small gaiter of the same material is 
laced over the malleoli and instep ; to this are attached the extending 
bands, which pass through the holes in the first cross-piece, and are 
fastened to the second or movable one. It may easily be seen that 
by turning the screw so as to separate the two cross-pieces, traction 
may be made on the extending bands to any desired extent ; and 
that the two splints, being pushed upward by the same mechanism, 
but prevented from yielding by the sockets of the knee-cap, tend to 
carry upward the knee, and with it the upper fragment. 

I have sometimes used this apparatus with advantage, especially in 
compound fractures; these are left so exposed that they maybe ex- 
amined and dressed without any derangement. It has the drawback 
of exerting considerable circular pressure upon the integuments of 
the knee and over the malleoli; the effects of this pressure may be 
obviated by wadding, but at some loss of tractile power, that is, of 
force to overcome very obstinate overlapping. The knee-cap, how- 
ever loosely applied, has the still more serious inconvenience of ob- 
structing the venous circulation ; and in one case of extremely com- 
plicated fracture, which I could not keep in place by any apparatus, 
I had to abandon it, on account of the very troublesome engorge- 
ment to which it gave rise, involving the entire limb as well as the 



640 A TREATISE ON FRACTURES. 

wound. Renaud, in 1812, contrived one almost similar to this; only 
.in place of a knee-piece, a strap was buckled around the thigh, with 
two leather sockets for the splints ; the strap and gaiter were both 
made of leather, softly padded with wool.* I doubt whether the re- 
tardation of the venous blood would be any less from constriction of 
the thigh than from that of the knee. 

[A very simple method of making extension may be readily 
adapted to the fracture-box before mentioned ; the first publication of 
it was made by Dr. Neill of Philadelphia, in 1855. The box should 
be made to reach somewhat higher than usual, and a hole should be 
bored in each side near its upper end. Extension may be made with 
adhesive plaster, precisely as in fractures of the thigh, (see ante, 
p. 585,) the lateral strips reaching up as far as the seat of fracture. 
Counter-extension may be made with adhesive strips, fastening them 
to the limb just as for extension, and connecting them to the splint 
either immediately, passing their ends through the holes above men- 
tioned, or by means of strips of bandage ; this latter may be readily 
and neatly done by wrapping the end of the adhesive strip around a 
bit of strong stick, and cutting a longitudinal slit in the strip, through 
which to pass the piece of bandage. Another way of making counter- 
extension is by laying a piece of bandage on each side along the 
upper part of the leg ; binding them in place by means of circular 
turns, and then bringing up the lower ends and passing them through 
the holes, tying together the corresponding ends as firmly as may be 
judged expedient. The former is the preferable plan.] 

But the fractures least manageable by the forms of apparatus 
hitherto in use are undoubtedly such as are oblique, with separation 
of the fragments and projection of the upper one. 

Pott was the first, if I mistake not, to write concerning the cause 
and treatment of this projection. He relates that an English sur- 
geon, whose name he does not give, invented a machine for correct- 
ing it, modeled on J. L. Petit's tourniquet. Pott disapproves of try- 
ing to push in the prominent portion ; according to him, the only 
rational plan is to raise up the lower fragment to the level of the 
upper ; the lateral decubitus, and semiflexion, always sufficing for 
this. Dupuytren defends Pott's views in this respect, but as his suc- 
cess with the lateral decubitus was far from being constant, he thought 
it proper to modify the position according to the direction of the 
obliquity, and proposed this general rule : 

" When the obliquity runs from one side to the other, the limb 
should rest, semiflexed, upon its posterior face; when the obliquity 
runs from before backward or from behind forward, it should lie on 
its outer face." 

* Kenaud, Observ. sur une fract. comminutive de la jarribe droite, suivie de 
Utanos, Grenoble, 1812. 



A TREATISE ON FRACTURES. 641 

Boyer is strangely silent on this point, and advocates the extended 
position of the limb. M. Ph. Boyer, although a faithful observer of • 
his practice, has deemed it right to deviate from it in the case in 
question : he does not hesitate to advise putting the limb in semi- 
flexion, and on its outer side. M. Mayor, returning to the oldest 
idea of all, has proposed compressing the upper fragment by means 
of handkerchiefs widely folded, and M. Laugier has resorted to sec- 
tion of the tendo-Achillis. Such was the state of the question when 
I took it up. 

Every one knows that if the limb is kept stretched out, it is in the 
immense majority of cases impossible to overcome the projection of 
the upper fragment. Should we succeed better by following Pott's 
advice in regard to position? The best proof to the contrary is, that 
Dupuytren was obliged to modify it. But even with his modifica- 
tions, was he certain of his results ? I have seen him apply his 
method in a perfectly simple oblique fracture; it solidified with a 
marked prominence.* As for compression exercised upon the upper 
fragment, either with handkerchiefs or with the tourniquet, it rapidly 
induces gangrene of the integuments ; the surgeon spoken of by 
Pott, having employed his machine in a case of simple oblique frac- 
ture, only converted it into a compound one; and I have cited other 
analogous cases. As for section of the tendo-Achillis, M. Laugier 
himself confesses that it did not entirely correct the projection; it 
moreover gave rise to an abscess, followed by burrowing of pus, and 
finally by the death of the patient. | 

This then is the question which presents itself: what is the result 
in oblique fractures with projection, since remedies are so powerless? 
In the first place, in a certain number the projection is but moderate, 
and is allowed to remain, the patient having only to wait three or 
four months for complete consolidation to occur. If the prominence 
is more marked, the callus formed exhibits a notable degree of 
deformity; the point of the bone distends the skin, which is thinned 
and threatens to ulcerate. I have elsewhere (page 278) mentioned 
the case of Meyranx, in whom ulceration and almost constant pain 
were kept up until death, by a projection of this kind. Too often 
also the fragments unite at an angle, and an irremediable limp is 
added to the deformity. Lastly, sometimes the projection cannot be 
corrected; the point of bone irritates the skin, and protrudes through 
it by inducing mortification; the only resource of art is then to resect 
the broken end, unless the case should assume a still more serious 
aspect. I have seen the skin thus perforated, and the patient re- 
duced to such a state as to necessitate amputation of the thigh. As 
for vicious consolidation, I saw so many cases of it at Bicetre, that I 

* See the Gazette Medicate, 1832, p. 39. 
f Laugier, Bulletin Chirurgical, tome ii, p. 253. 
41 



642 A TREATISE ON FRACTURES. 

at last left off collecting them; and they came from nearly all the 
. hospitals in Paris. 

It was in 1840 that I first had to contend with difficulties of this 
sort. An insane patient had broken his leg by a fall, and the upper 
fragment, very sharply pointed, threatened to pierce the skin. I 
tried different forms of apparatus and different positions ; I should 
note here that great elevation of the limb succeeded a little better 
than the other plans. I inclosed the part in a plaster mould; the 
upper fragment was tilted up so strongly as to crush, as it were, the 
integuments against the plaster, and I was compelled to abandon the 
attempt. It was evidently requisite to make firm and constant 
pressure on the fragment, and yet not to bear upon the integu- 
ments ; and in view of this necessity I devised my screw apparatus. 
This is made of a sort of bow of strong sheet-iron embracing the 
anterior three-fourths of the leg, leaving an interspace of a finger's- 
breadth between it and the surface; at each end of this bow is a 




horizontal mortise; through this there is passed a strong silk or cot- 
ton band, with a buckle at one end; and lastly, at the centre of the 
bow is a solid nut, through which plays a very sharply-pointed screw, 
for making the pressure. (See cut.) 

In applying this machine, I place the limb on a double inclined 
plane, properly padded with wadding or linen, taking care that the 
angle of the apparatus answers exactly to the ham, or is even a little 
above it, so as never to let it bear against the upper fragment. 
Another and no less essential precaution is to arrange beneath the 
tendo-Achillis a sufficient thickness of padding to prevent the heel 
from being directly rested upon. Extension and counter-extension 
being duly made by assistants, the instrument is applied as follows: 
the free end of the band, withdrawn from the mortise at that end of 
the bow, is passed beneath the inclined plane just at the level of the 
point at which pressure is to be made ; it is then passed through the 
mortise again; the other extremity is then applied above the bow, 
the screw being let into a hole in the band, near the buckle. The 
bow is adjusted over the limb, and the band passed through the 



A TREATISE ON FRACTURES. 643 

buckle, ready to be tightened. The surgeon now makes coaptation 
as exactly as possible, keeping it up by pressing upon the upper 
fragment with the fore and middle fingers of the left hand; he fits 
the bow and its screw so that the latter shall,strike the fragment in 
the precise direction requisite, still preventing by means of his two 
fingers its unnecessarily lacerating the skin. He now tightens the 
band as much as possible, and rapidly turning the screw, drives its 
point without hesitation through the skin and into the inner face of 
the bone, increasing the pressure to any degree he may think proper. 
It is better that the instrument should act nearly or quite two inches, 
at least, from the seat of the fracture. 




The patient experiences at the moment of the puncture a slight 
pain, which however soon passes off. If he is willing to remain at 
rest, the point may be kept in for fifteen, twenty, perhaps thirty-six 
days or more, without inducing either inflammation or suppuration, 
or even redness ; and if it does not slip from being inserted too 
obliquely into the inner face of the bone, the little wound left when 
the instrument is removed will heal up in about twenty-four hours. 
I first published two successful cases; M. Davasse has since given 
several others ;* and the apparatus has always proved as harmless 
as it is efficient. In the majority of cases there remains not the 
slightest prominence on the surface of the bone. In one instance 
reported by M. Davasse, the point had induced the deposit of a little 
bony tubercle, hardly sensible to the touch, and completely painless, 
but which had not disappeared after the lapse of eighteen months. 

[Dr. Christopher Johnston, of Baltimore, tells me that in 1852 he 
saw this contrivance used with perfect success in two cases, under 
the care of M. Malgairrne himself.] 

I have said that the point may slip in consequence of the intracta- 

* Malfraifrnc. Xouvelle me'thode de traitem. pour Its fr act. tres-obliques de la 
jambe, Journal de dor.. September, 1843; Davasse, Obs. sur V emploi d < /'"/>- 
pareil a vis dans le traitem. des fract. obliq. de la jambe, Archw. Gin. de 
Mtdecine, July, 1846. 



644 A TREATISE ON FRACTURES. 

bility of the patient; this is because there is in fact no penetration 
of the bone, however great the pressure applied. In slipping, the 
point lacerates the integuments, producing a small wound which is 
sometimes ten or twelve days in healing; but even then there have 
never occurred any further symptoms. Sometimes at the end of five 
or six days the point begins to be unsteady, from the yielding of the 
pads and of the tissues; then the strap should be tightened, or the 
screw turned. Lastly, when the thread of the screw runs too wide 
the action of the muscles frequently suffices to turn it back, lessening 
the amount of pressure ; this is to be prevented by tying the head 
of the screw. 

Such is the method, a novel one to be sure, which I have used so 
often as to place its efficiency beyond a doubt. It maintains the 
fragments in close contact, so that they are not deranged by moving 
the foot upon the leg, and so that neither lateral splints nor perma- 
nent extension are necessary; we need only prevent the falling of 
the foot outward. Consolidation ensues as quickly in the most 
oblique fractures as in any others; so that whereas I devised the 
plan for cases in which perforation of the skin was threatened, 'I 
employ it at present in the majority of oblique fractures, merely to 
insure firm union. 

It is especially in compound fractures that I have found this in- 
strument invaluable ; by insuring complete immobility of the frag- 
ments we allay the inflammation, and diminish the amount of sup- 
puration ; I have succeeded in obtaining consolidation in forty days, 
in splintered fractures communicating with the external air by lace- 
rated wounds. In one case, indeed, there was a large splinter lying 
loose between the tibia and fibula; this remained movable, but con- 
solidation ensued rapidly, without any suppuration taking place. 

There are however some compound fractures which cannot be kept 
in place even by this means. The wound is so large, and the frag- 
ments are so stripped and loosened, that they both equally need re- 
tention. I have twice used two screws, one applied to the upper and 
the other to the lower fragment. In a still more troublesome case, 
even this did not suffice to keep up the coaptation; I tried passing 
around the broken ends a thread ligature, and afterwards one of 
wire, to hold them together, — almost a desperate attempt ; and in- 
deed most of my efforts of this kind failed; but I have succeeded at 
least once in preserving a limb which, but for the adoption of such 
extreme measures, would have been condemned to amputation. 

I shall add but a few words, in relation to certain deformities re- 
sulting from such fractures of the leg as are totally neglected. In a 
case in which the fragments formed an acute angle opening back- 
ward, M. Josse, of Amiens, resected both bones, affording the pa- 
tient a limb which, although shortened, was well-shaped and capable 
of fulfilling all its functions. I have myself had a similar operation 



A TREATISE ON FRACTURES. 645 

to perform in a nearly similar case ; unfortunately the wound was 
attacked with hospital gangrene, and the patient perished; but the 
autopsy showed that there had been no burrowing or purulent de- 
posits in the limb, so that apart from the accidental condition set up, 
a favorable result might have been looked for. [A very favorable 
case of this kind is related in a note on p. 274.] 



§ II. — Fractures of the Tibia. 

Fractures of the tibia alone are quite rare, compared with those of 
both bones ; which rarity is accounted for when the causes producing 
them are inquired into. 

These causes are direct or indirect. Thus, the patient being first 
overthrown, the leg may be crushed by the fall of some heavy body 
upon it, or by the passage of a carriage-wheel over it; and it is 
easily seen how unlikely it is that a pressure or a blow sufficiently 
forcible to break the tibia should be unable to overcome the slight 
resistance of the fibula. If on the other hand the patient is standing 
up, and the tibia receives the shock, the giving way of this bone 
throws the whole weight of the body upon the fibula, which is un- 
equal to the support of such a load ; the same occurs when the tibia 
is first fractured by a false step or a fall from a height upon the 
feet ; the fibula rarely escapes unbroken. 

There is however no surgeon who has not sometimes seen fracture 
of the tibia alone, or at least without any recognised injury of the 
fibula. Either extremity of the bone, or its shaft, may be affected. 

These fractures may be serrated, oblique or comminuted. I have 
elsewhere said, and I would now repeat, that the fractures described 
by authors as en rave have never been observed. 

The symptoms are severe local pain, increased by pressure or by 
any attempt at walking; swelling, and sometimes ecchymosis. Dis- 
placement rarely exists; the uninjured fibula serves not only as a 
lateral splint, but plays the part of an extending apparatus, opposing 
an almost invincible obstacle to overlapping. Thus patients with 
this form of fracture have been known to walk, in spite of the pain. 
Nevertheless, in consequence of the external violence, one of the 
fragments may be made to encroach upon the interosseous space, 
and the other to project inward, or inward and forward; to speak 
more accurately, in the majority of instances, it is the whole lower 
portion of the leg which is carried outward, or backward, or oven 
forward, from the upper fragment; the mobility of the peronco-tibi;il 
articulation above allowing this to occur without any other rupture 
taking place. This kind of displacement is easier, the nearer the 
fracture is to the knee-joint; thus Boyer saw a case in which the 
upper part of the tibia was broken by the kick of a horse, in which 



640 A TREATISE ON FRACTURES. 

the fragments were so displaced that they could not be adjusted, 
and the bone remained warped forward. In the Muse'e Dupuytren 
(No. 212) is a fracture at the upper third of the tibia, the fragments 
in which are carried backward and outward so as to form an angle of 
160°, and to narrow considerably the interosseous space. 

Sometimes also there occurs partial separation of the two bones at 
their lower extremities, favoring this displacement; lastly, in young 
subjects, the fibula may bend without breaking, or as the result of 
incomplete fracture; I have more than once caused such curvatures 
of the fibula in animals, after having broken the tibia; and I have 
elsewhere cited M. Campaignac's remarkable case of a girl twelve 
years old, whose tibia had been fractured at its middle by the wheel 
of a cabriolet. The lower fragment projected forward and inward; 
the leg could not be completely restored to its natural form, and the 
callus was deposited with a slight angle in the direction mentioned. 
The patient dying some time after, dissection revealed an incomplete 
fracture and a curvature of the fibula.* 

Finally, fracture sometimes affects the tibia above its upper articu- 
lation with the fibula, and then of course the latter bone can present 
no obstacle to displacement. Fig. 86 would afford an example of 
this, were not the fibula also broken. Sometimes, as in this figure, 
the line of fracture runs downward and forward ; or it may be oblique 
from one side to the other, as in the partial fracture represented by 
M. Campaignac. I have seen a case in which this portion of the 
tibia seemed to be crushed; the upper fragment has been seen di- 
vided into two parts ; lastly, what forms a more important difference, 
the knee-joint may or may not be concerned; the joint however is 
generally entered, when there ensues effusion as considerable as in 
fractures of the patella or of the femoral condyles. As to other 
phenomena, there may be no appreciable displacement, doubtless 
owing to the serrations and the periosteum keeping the fragments in 
contact ; but we more commonly find the upper fragment tilted up by 
the quadriceps, acting upon it without any opposition; and the pro- 
minence which it makes in front is the more pronounced in proportion 
as the knee is more flexed. 

On the whole, these displacements rarely go so far as to give rise 
to any serious deformity ; often, on the contrary, the perfect contact 
of the fragments prevents crepitation, and our diagnosis can be only 
a probable one. We may, however, infer the existence of fracture 
when the patient, after sustaining a fall or a blow, experiences at 
one portion of the tibia a sharp and circumscribed pain, persistent, 
increased by pressure or by any attempt at walking, attended with 
some engorgement; and especially when his sleep is disturbed by 
startings of the limb. If in running the finger along the spine of the 

* Journal Hebdomadaire, tome iv, p. 100. 



A TREATISE OX FRACTURES. 647 

tibia we perceive any inequality; if by pressing the fragments in 
opposite directions we can detect mobility or crepitation, our diag- 
nosis is rendered almost certain. 

I do not say that it is quite certain, because it remains to be decided 
whether the fracture is limited to the tibia, or involves the fibula 
also. Now, not only is this differential diagnosis not always easy, 
but as was said in connection with fractures of the leg, slightly 
marked as the fracture of the fibula may be, and careful as our in- 
vestigations must be to detect it, prudence should forbid our going 
too far, making us willing rather to remain in ignorance of a compli- 
cation which can have no influence on our remedial measures. 

The treatment is very simple; when there is no displacement, or 
when the displacement, being reduced, does not tend to recur, it is 
sufficient in many cases to keep the limb lying on a cushion for 
thirty-five or forty days, which is about the time required for consoli- 
dation. It is always safer however, in order to avoid any risk of 
displacement, to support the leg either by lateral splints, by an im- 
movable apparatus, or upon a double inclined plane. I prefer using 
the double inclined plane or the lateral splints for the first few days, 
until there is no longer any fear of inflammation ; but after that, the 
dextrinated bandage has the recommendation of enabling the patient 
to go about on crutches. 

The only inconvenience to be apprehended is troublesome stiffen- 
ing of the articulations. This is to be obviated by slight flexion, if 
the patient is compelled to observe perfect rest; by careful move- 
ments at the knee and ankle, when there is no contra-indication. 

Fractures at the upper end of the bone generally entering the 
joint, absolute rest is essential; the thigh must then be confined as 
well as the leg, and it is then particularly that the knee is apt to be- 
come rigid. Slight flexion of the leg upon the thigh is therefore 
preferable unless the fragments have a tendency to become displaced. 

But when the upper fragment is carried forward by the action of 
the quadriceps muscle, the least degree of flexion tends to increase 
the displacement, which diminishes or disappears when the leg is 
straightened out. Syme resorted to extension in one case of frac- 
ture at the upper end of the bone, communicating with the joint;* 
and I should not hesitate to employ it, for my own part, if the dis- 
placement were sufficiently remedied in that way. But in cases 
requiring more efficient means, I should much prefer putting the 
limb in a slightly flexed posture on the double inclined plane, and 
correcting the projection of the fragment by applying the screw 
described i« the foregoing section. 

Sir A. Cooper has thrown out some ideas, in regard to fractures 
of the upper extremity of the tibia, which may perhaps be somewhat 

* Arcltiv. G6n. de Mtdccine, 1836, tome xi, p. 97, 



648 A TREATISE ON FRACTURES. 

unsafe. When the joint is involved, he advises extension of the leg 
on the thigh, in order that the femoral condyles may act as a hori- 
zontal splint upon the articular face of the tibia, and keep it in exact 
position; moreover he advises approximating the fragments antero- 
posteriorly by means of a pasteboard splint and a roller. This 
splint and bandage would seem to fulfil the same indication as my 
screw apparatus, but with less certainty, and with the danger of 
continuous pressure upon the skin covering the bone. As to the 
efficiency of the condyles of the femur by way of a splint, it needs 
only to be remarked that they do not press much more against the 
tibia in complete extension than in slight flexion of the knee. 

But if the fracture, although oblique, does not penetrate the joint, 
Sir Astley recommends the double inclined plane, provided, says he, 
that the deformity is the result of the riding up of the lower por- 
tion, and that it is obviated by the weight of the leg upon the plane. 
The best proof that the upper fragment may be displaced by itself, 
without any overlapping of it by the other, is that it has been seen 
projecting anteriorly even in fractures at the middle of the bone, 
when the resistance of the fibula prevented the occurrence of any 
overlapping whatever. Sir Astley Cooper was therefore misled by 
an idea more plausible than correct, and moreover unsupported by 
any observations. 

§ III. — Fractures of the Fibula. 

In our resume of cases at the Hotel-Dieu, of 515 fractures affect- 
ing the bones of the leg, only 109 involved the fibula by itself. This 
proportion is evidently too small; since during the interval from 
1806 to 1808 they were frequently confounded with simple sprains. 
In fact, within that time only twelve of them were detected among 
150 fractures of the leg, making them amount to less than one- 
twelfth. Dupuytren would have it, on the contrary, that they were 
to all other fractures of the leg in the ratio of one to three, which 
seems to me to be the opposite extreme. From 1830 to 183T, the 
registers of the Hotel-Dieu record 97 fractures of the fibula to 365 
of the leg, or a little more than one-fourth. This is nearly the same 
proportion as that found by Lonsdale himself at the Middlesex Hos- 
pital, 51 to 197, and is the one which seems to come closest to the 
truth. 

In examining our 109 cases in reference to the influences of age 
and sex, we arrive at some quite curious results. In the first place 
there is not one below the age of fifteen, and from fifteen* to twenty- 
five they are still quite rare, there being only thirteen. From twenty- 
five to fifty we find seventy-one, almost two-thirds of the whole 
number; the fracture in question is therefore one in great measure 
peculiar to adult age. Between fifty and seventy years there are 



A TREATISE OX FRACTURES. 649 

twenty, and only five between seventy and eighty; above this there 
are none at all. 

Since it belongs to adult age, this fracture ought to occur much 
more commonly in men ; the general proportion is eighty-eight to 
twenty-one. — more than quadruple; but this varies remarkably ac- 
cording to age. Thus we find 

From 15 to 25 years .... 8 males, 5 females. 

25 to 50 " 64 " 7 " 

50 to 70 " . . . _ 14 " 6 " 

- 70 to 80 " 2 " 3 " 

It would seem more frequent in winter than in summer ; the last 
three-quarters of the year do not present any great difference in 
this respect, giving in all sixty-seven cases; but the first quarter 
by itself has forty : two. 

Lastly, Dupuytren, having collected 207 cases, says that seven- 
tenths, or more than two-thirds of them, involved the right leg.* 

The fibula is rarely broken by direct causes, such as the passage 
of a carriage-wheel, the shock of a heavy body falling or violently 
propelled, etc. Indirect causes much more commonly give rise to it, 
and have therefore attracted much more attention among surgeons. 

David, in 1771, under the name of Bazille, spoke of a fracture 
produced by falling obliquely upon the feet, but gave no further ex- 
planation. Pouteau, believing that he had detected this fracture 
after missteps which had not even been followed by the patient's 
falling down, thought they might be occasioned by the mere commotion 
from violent contraction of the peronei muscles.f Boyer was the 
first to assert that the fibula is broken in two quite different ways, 
by violent adduction or abduction of the foot. In the first, says he, 
the astragalus pushes outward the lower extremity of the fibula; in 
the second the latter bone is acted on from below upward by the 
calcaneum. This view, although purely hypothetical, seemed plau- 
sible, and was quite generally adopted. 

Dupuytren himself, although affecting to ignore Boyer's statement, 
borrowed from him the basis of his doctrine, acknowledging pro- 
line causes as efficient. His explanation was somewhat 
different; in adduction he admitted the pressure of the astragalus 
within outward against the external malleolus, but added the 
traction exerted upon that process by the lateral ligaments, this lat- 
ing in his opinion the essential agent in producing the fracture. 
I ion, lie denied that any pressure was made by the cal- 

* Dupuytra " '-mite inf. dup4ron£, etc., Armuaire 

da Hi , Paris, 1 819. 

zille, Mif%. '■'■., Prix de V Academic />'• 

//'-. tome iv. ]». 572 ; Pouteau, M6m. sur Its fract. du piront, Q2w • 

. tome ii, p. 2 



650 A TREATISE ON FRACTURES. 

caneum ; according to him the first effect of forcible abduction is to 
break either the internal lateral ligament or the inner malleolus ; and 
the fracture of the fibula, always consecutive, is then "caused by the 
change made in the line of transmission of the weight of the body, 
which in place of coinciding with the axis of the limb and falling 
upon the astragalus, abandons that axis, and strikes at some point 
about the lower extremity of the fibula." This theory was defended 
both by observations and experiments. Thus of 207 fractures of 
the fibula, setting aside one-tenth as due to direct violence, the re- 
mainder were divided as follows: 

•6, were produced by forcible adduction of the foot; 
•3, " " " abduction " " 

His experiments were these. The foot of a dead subject being 
fixed in a vice, so as to leave the tibio-tarsal articulation free, by 
carrying the upper part of the leg forcibly inward, which was the 
same as making strong adduction of the foot, fracture of the exter- 
nal malleolus without displacement was the constant result; by car- 
rying the upper part of the leg outward, or making abduction, 
fracture of the inner malleolus was first produced, and subsequently 
the fibula gave way at its lower extremity. Finally, if instead of 
fixing the foot in a vice, points oVappui were taken upon one of its 
edges, adduction always caused fracture of the fibula at a higher 
point than in the preceding experiments. 

M. Maisonneuve has repeated these researches, but not with en- 
tirely similar results.* Thus he has always seen the internal lateral 
ligament ruptured by forcible abduction, without any fracture either 
of the internal malleolus or of the fibula; he therefore rejects the 
idea of fracture by abduction. By adduction, on the contrary, he 
has easily succeeded in fracturing the external malleolus, but always 
transversely, and on a level with the lower end of the tibia. He 
admits therefore a fracture by adduction, produced by traction on 
the ligaments, as pointed out by Dupuytren, but essentially limited 
to the outer malleolus; and he gives it the name of fracture par 
arrachement, [by tearing off.] 

But it is not, according to him, in this way that most fractures of 
the fibula take place ; it is chiefly by a rotation of the foot, by which 
its point is carried outward, "when for instance, the foot being caught 
between two stones in a pavement, the body moves forward and in- 
ward; or perhaps when, twisting upon its inner border, the foot is 
deviated outward and backward, while the leg is either fixed by the 
weight of the body, or turned in the contrary direction." In such 
a movement, the foot represents an inflexible stem jointed at a right 
angle with the mortise formed by the tibia and fibula, and pressing 

* Maisonneuve, Recherches sur lafrad. du pironi, Archiv. G6n. de M<2de- 
cine, Feb. and April, 1840. 



A TREATISE ON FRACTURES. 651 

the external malleolus from within outward and from before back- 
ward. If we imagine a fixed mortise into which a lever is intro- 
duced perpendicularly, and a force applied to the upper end of this 
lever so as to incline it, one of the sides of the mortise must in- 
evitably be broken; and this is what takes place in the foot. Now 
why should the outer malleolus be broken rather than the inner? 
On account mainly of the arrangement of the lever. Suppose the 
foot to be five inches in length from the point of the toe to the pos- 
terior border of the astragalus, and the portion of this bone engaged 
between the two malleoli to be one inch in length; when the point of 
the foot is carried outward, the foot itself acts upon the tibia as a 
lever of the first order, taking its fulcrum on the anterior edge of 
the fibula; the resisting arm will have a length of one inch, and the 
other a length of only four inches. But upon the fibula the foot 
acts as a lever of the second order, taking its fulcrum on the pos- 
terior edge of the inner malleolus. The resisting arm will still have 
its length of one inch, but that of the other arm will be five inches; 
whence it is evident that the lever must act much more powerfully 
upon the outer malleolus than upon the inner. M. Maisonneuve 
calls the resulting fracture a fracture by divulsion. 

It sometimes, however, happens that the malleolus resists, and that 
the whole of the force is spent upon the ligaments connecting the 
foot with the tibia. These ligaments being ruptured, the fibula is 
separated from the tibia as well as carried backward; and if the 
muscles, the interosseous ligament, and, above all, the attachments 
of the upper articulation oppose too great a resistance to this double 
movement, it is the fibula itself which yields, as if by a kind of tor- 
sion; the fracture is always situated higher up than the two pre- 
ceding forms are, generally involving the superior third of the bone ; 
and since it is always preceded by separation of the two bones, 
M. Maisonneuve calls it a fracture by diastasis. 

Such are the theories which have hitherto prevailed in reference 
to indirect fractures of the fibula. Now in order to judge of their 
incorrectness, we need only say that experimenters, by forcible ad- 
duction of the foot or of the leg, have never been able to procure 
any fractures but those of the outer malleolus, and that their "frac- 
ture by arrachement" has nothing to do with fractures of the fibula, 
properly bo called. A more curious fact in regard to "fracture by 
diastasis" is, that it has not yet been observed in the living subject, 
and that the unique example of it reported by M. Maisonneuve turns 
out to be a fracture of both bones. 

Let as now leave these problematical lesions, and return to actual 
facts. Now it is constantly seen by practitioners that indirect fractures 
of the fibula, as occurring in the living subject, are generally sen ted 
about two inches above the tip of the malleolus, — rarely either higher 
up or lower down. According to the statements of our patients, 



652 A TREATISE ON FRACTURES. 

the injury is for the most part produced by forcible adduction of the 
foot ; that is to say, as the effect of a fall or a misstep, bringing the 
weight of the body upon the outer edge of the foot. It seems to me 
very difficult to determine the precise mechanism; I would only re- 
mark that this adduction of the foot is ordinarily accompanied by 
an inclination inward of its point. This is all we can obtain from 
observation; and in order to avoid hypothesis, I shall name these 
fractures, from their cause, fractures by adduction. 

Others are ascribed by the patients to a fall or a misstep, by 
which the weight of the body is thrown on the inner edge of the foot, 
which is therefore abducted. M. Maisonneuve rejects this evidence, 
and would make out that the fracture is due to rotation outward of 
the point of the foot. Now if the reader will try for a moment to 
walk on the inner edge of the foot, he will be convinced that by this 
movement the point of the foot is almost unavoidably directed out- 
ward; so that the fracture then takes place at once in the manner 
described by the patients and according to the mechanism so clearly 
pointed out by M. Maisonneuve. It is in my opinion only in very 
rare and quite exceptional cases that rotation of the point of the 
foot acts by itself, without abduction of the whole foot; and for this 
reason I should prefer the name of fracture by abduction to that of 
fracture by divulsion; the latter having but a limited application, 
while the former is derived from the most general cause. 

Such, then, are the two great divisions of indirect fractures, — 
those by adduction and those by abduction. Not that I would assert 
that no other varieties exist; M. Rognetta, for example, has pro- 
duced them in the dead body by making forcible extension of the 
foot ; * and if we consider the diversity of circumstances under which 
fractures of the fibula occur, by the foot striking a stone, or meeting 
with a hollow or an inequality in the ground, by its slipping away 
from the other, or being caught between two of the stones of a pave- 
ment, resting on its point or its heel, on its inner or outer edge, its 
point inverted or everted, the leg flexed or extended; if we add to 
this the different attitudes, and especially the weight of the body, 
which is an element wanting in all experiments on the dead subject, 
we must perceive that the most comprehensive theory would hardly 
embrace such manifold conditions. Moreover, this would be of little 
practical value, since it is very rarely that the patient can give an 
accurate account of the way in which his accident happened. 

May we not, however, refer to the two grand causes indicated 
some special forms of fracture, so that, the fracture being recognised, 
we may trace it to the cause producing it? There is one at least in 
which this retrospective diagnosis would seem extremely probable; it 
is the one which M. Maisonneuve has particularly studied. 

* Archw, G6n. de Mtdecine, 1833, tome iii, p. 499. 



A TREATISE OX FRACTURES. 653 

A woman, thirty-five years old, having made a misstep in descend- 
ing a staircase, sustained a fracture of the fibula, and at the same 
time one of the skull, and died a few hours afterwards. The former 
of these injuries is represented in Fig. 94. The line of division runs 
downward and forward, and a little inward, beginning at the poste- 
rior edge of the bone five centimetres above the point of the malleo- 
lus, and ending in front two centimetres above it, vertically, just on 
a level with the articular face of the tibia. The upper fragment 
remained adherent to the tibia ; the lower one was separated from it 
and thrown outward and backward, so that, while still in contact with 
the other by its posterior edge, the two were apart anteriorly by two 
or three centimetres, leaving between them a triangular space; the 
apex of this space being upward and backward, and its base downward 
and forward. This separation was greatly increased by carrying the 
toes outward, but disappeared when they were turned inward. Neither 
abduction nor adduction had any effect on these phenomena, so that 
it might justly be inferred that eversion of the point of the foot was 
the main agent in both the fracture and the displacement. 

I have met with several cases of this kind in the living body; and 
the account of the patients has more than once corroborated the in- 
ference drawn from the form of *he fracture. But we are not so well 
informed in regard to other varieties. 

Fig. 95 represents a recent fracture at the lower extremity of the 
fibula ; it is oblique from above downward and from without inward, 
commencing two inches above the point of the malleolus, and run- 
ning down to just about the middle of the peroneo-tibial junction. 
Fig. 96 La an exactly similar case, except that there is a pretty 
marked separation of the lower fragment outward. On the other 
hand. M. Pigne has deposited in the Musee Dupuytren a remarkable 
specimen, (No. 232,) in which may be seen, besides a tearing off of 
the tibial malleolus, a fracture running very obliquely downward and 
backward, in such a way that, beginning on the anterior surface of 
the fibula, nearly four inches above the malleolus, it terminates pos- 
teriorly about two inches above it. The lower fragment is carried a 
little in front of the upper. 

The first question which arises is, To what variety do these frac- 
tures belong? I presume, but cannot assert, that they are the result 
of adduction. Can it be deduced from this that fractures by adduc- 
tion are characterised by obliquity downward and inward, or down- 
ward and backward, while those of the other form have their special 
obliquity downward and forward? This would be a very bold as- 
sumption ; and Dupoytren'e seventeenth observation clearly shows a 
fracture by adduction, transverse, and seated an inch and a half from 
the malleolus. On the other hand, his twenty-sixth and twenty- 
seventh observations have reference to very oblique fractures, which 
were due to direct violence. Still, it may be stated as a general rule 



654 A TREATISE ON FRACTURES. 

that indirect fractures present a certain obliquity, while the direct 
are usually transverse. 

Fig. 97 shows a direct fracture seated, like the preceding, about 
two inches above the malleolus ; it is nearly transverse. 

Direct fractures may affect any portion of the bone, and present 
no peculiar phenomena. It is but rarely that mobility and crepita- 
tion are perceived ; inequalities resulting from any displacement are 
quite as uncommon, and we must generally be content with a proba- 
ble diagnosis, derived from the cause, the fixed and persistent pain 
at the point of injury, and the accompanying ecchymosis. 

Sometimes, however, the lower fragment of the fibula is driven in 
toward the tibia so forcibly as to produce deviation outward of the 
malleolus, and consequent deformity of the foot. Fabre reports a 
fracture resulting from the passage of a carriage-wheel over the 
lower extremity of the leg. The swelling was considerable, but the 
foot retained its normal position ; it was only after the subsidence of 
the swelling that the foot was seen to be thrown outward, and the 
patient was permanently lamed. Dupuytren has published a still 
more remarkable case, in which the displacement seemed to have 
been the effect of the fracture itself.* The same author says also 
that he has seen in two or three »patients, and in a much greater 
number of dead bodies, one of the fragments projecting outward and 
the other driven in ; but the information given concerning these 
cases would seem to indicate that the displacement was due much 
less to the fracturing cause or to muscular violence than to the ap- 
plication of a very tight circular bandage. I have for my own part 
never met with anything of the kind. 

As to fractures by adduction, the first point which it is important 
to establish, contrary to the usual views of authors, is that in the 
majority of cases there is no displacement whatever ; that the injury 
is recognised, like a direct fracture, only by the pain and ecchymo- 
sis. It is not uncommon to see patients walking in spite of this frac- 
ture ; and I saw one man who. was able to go a league on foot, to his 
home, without at all disturbing the exact contact of the fragments. 
Dupuytren has indeed reported two analogous cases, i.e., without any 
displacement ; but being preoccupied with the idea of bringing his 
apparatus into use, he saw in them only exceptions ; and in his sta- 
tistical summaries he asserts that nine-tenths of his fractures were 
attended with displacements. There remains, therefore, but one- 
tenth without displacements, and when it is remembered that he esti- 
mated one-tenth of his fractures to be direct, it may be seen that his 
idea was that displacement almost necessarily accompanied every 
indirect fracture. Now I do not hesitate to declare that in regard to 

* Fabre, Recherches sur diff. pozntes de physiologze, etc., 1783, tome i, p. 299; 
Dupuytren, op. czt., obs. 27. 



A TREATISE ON FRACTURES. 655 

this, Dupuytren Las led other surgeons into error; and that his re- 
sults are irreconcilable either with my own personal experience, or 
with what I have seen in his wards at the Hotel-Dieu. I repeat, in 
order that no doubt may remain; in most cases of fracture produced 
by adduction of the foot, there is neither displacement, Bwelliag, nor 
deviation of the foot ; it gives the patients pain to walk, and they 
put the foot to the ground only very cautiously ; some instinctively 
try to rest on its outer edge ; but these signs are common to sprains 
as well as fractures. Ecchymosis is in my opinion an almost charac- 
teristic symptom ; for I do not think I have ever observed it in a 
mere sprain. But an easy and certain means of diagnosis between 
the two lesions consists in pressing with the thumb over the lateral 
ligaments, and then over the outer surface of the fibula at three, five 
or seven centimetres from the point of its malleolus ; pain on pres- 
sure upon the ligaments indicates a sprain ; pain at some one point 
in the bone belongs almost exclusively to fracture. 

Why then is it that in Dupuytren's observations fractures by ad- 
duction would appear to be so often complicated with displacement, 
and consequently with luxation of the foot ? The facts answer for 
themselves ; it is because all patients, having had the fibula broken 
by forcible adduction, still attempt to walk ; and then the foot is 
turned outward into abduction, giving rise to displacement and all its 
consequent symptoms. This secondary displacement occurs some- 
times even in direct fracture, when the patient rests on the outer 
edge of his foot ; Dupuytren has given several such instances. 

But is fracture by adduction never attended with any displacement 
of any kind? Although I have not seen it myself, I would not deny 
its possibility. Dupuytren's ninth observation is the case of a woman 
fifty years old, who in going down a staircase made a misstep, bringing 
the weight of her body upon the left foot, which was put out for- 
ward and somewhat inward ; the left leg bent on the thigh, and slid 
with the body along down the staircase, bearing upon its outer side. 
An extensive abrasion was presented on the external surface of the 
foot and leg ; the fibula, broken two inches above the tip of its mal- 
leolus, was movable, and could be pushed toward the tibia with a 
perceptible crepitus. There was no visible displacement, pi^minence 
of the malleolus, depression above it, deviation, nor rotation of the 
foot in any direction ; nevertheless, by fixing the leg with one hand, 
and with the other carrying the foot alternately inward and outward, 
the hitter could be made to move transversely over a space of at 
least an inch ; and then only there appeared some symptoms of luxa- 
tion outward of the foot. 

Such is Dupuytren's account; and now the question is whether or 
not the fracture was actually produced by adduction. I have seen 
several cases presenting exactly similar phenomena; in one I could 
not determine the precise cause of the lesion, but in all the rest there 



656 A TREATISE ON FRACTURES. 

had been abduction, with the toes turned outward. This is a point 
which ne'eds to be elucidated by further observation. 

It is evident, from what has been said, that fracture by abduction 
may itself occur without any appreciable displacement ; of this 
M. Maisonneuve gives two examples. In these cases, as in the pre- 
ceding varieties, the patient walks with great difficulty; there is 
ecchymosis, swelling, and local pain on pressure above the malleolus ; 
but moreover, by fixing the leg firmly and abducting the point of the 
foot, the malleoli are manifestly separated, often even with marked 
crepitation. 

When this separation is persistent, which is ordinarily the case, it 
involves other phenomena which it is important to consider. The 
foot is placed in abduction, especially marked at the toes ; sometimes 
its point alone is carried outward, the heel maintaining its ordinary 
direction. The inner malleolus projects beneath the skin, particu- 
larly by its anterior edge. The separation outward of the outer 
malleolus leaves above it a depression, or entering angle, to which 
Dupuytren gave the singular and not very intelligible name of coup 
de hache, [axe-stroke.] Tracing the anterior edge of the fibula, we 
come to the sharp prominence of the end of the upper fragment ; 
sometimes I have found this movable, so as to sink in under pressure, 
starting up again when left to itself. Finally, between this point 
and the malleolus, we detect the notch separating the two fragments, 
widening upon eversion of the point of the foot, and narrowing by 
its inversion. 

When the displacement is slight, although the articular surfaces have 
actually undergone some derangement, it may be taken for granted 
that the whole is to be ascribed to the fracture ; but the displacement 
cannot be carried very far unless there is a rupture either of the in- 
ternal lateral ligament, or of the inner malleolus itself, and conse- 
quently a true luxation of the foot. In the specimen represented in 
Fig. 94, there was at the same time* a complete detachment of the 
anterior annular ligament of the ankle-joint at its tibial insertion, 
and rupture of the anterior and middle fasciculi of the internal late- 
ral ligament. When the luxation takes place, all these phenomena 
are muck more marked, and sometimes the foot is so much abducted 
that its outer edge looks almost directly upward ; but this is not the 
proper place for discussing this lesion, which is much more serious 
than the mere fracture, and which strictly belongs under the head of 
luxations. 

The diagnosis, when there is no displacement, may waver between 
a fracture and a mere sprain; I have already mentioned the mode 
in which it can be rendered at least probable. I must insist here 
upon the necessity of care in forming the diagnosis; I have more 
than once seen these fractures undetected because no crepitation or 
displacement was present ; the least that can happen in such a case 



A TREATISE ON FRACTURES. 657 

is the persistence of pain until proper treatment is instituted, and in 
some unfortunate instances injudicious attempts at walking have 
given rise to luxation of the foot. When there is displacement, it is 
only necessary to examine whether or not it is attended with rupture 
of the internal lateral ligament or of the inner malleolus. 

The prognosis, when there is no displacement, is very favorable; 
and a slight degree of displacement, without any other complication, 
will yield quite readily to proper treatment. When Dupuytren de- 
scribed fracture of the fibula as so grave a lesion, it was because he 
thought fit to associate with it every species of tibio-tarsal dislocation, 
which should assuredly have been discussed separately. 

The treatment of these fractures without displacement is the simplest 
thing in the world; we may almost be content with keeping the limb 
at rest, and waiting for consolidation. It is however safer to guard 
against any sudden movement of the foot; if therefore there is any 
swelling, I place the leg and foot between two lateral cushions, sup- 
ported by two side-splints, admitting of the application of cataplasms 
if necessary ; the swelling having subsided, the foot and lower half 
of the leg should be enveloped in a starched or dextrinated bandage, 
and the patient may be allowed to go about on crutches. 

When displacement exists, the first point is to restore the foot to 
its proper direction, and to put the outer malleolus in contact with 
the tibia. This is generally easy; if necessary, reduction may be 
favored by flexing the leg, so as to relax all the muscles; and I 
doubt whether, except in cases of luxation, the surgeon need ever 
resort to the section of the tendo-Achillis, in imitation of M. A. Bd- 
rard.* But to keep the fragments in place is rather more difficult, 
and sometimes, either because the serrations do not properly inter- 
lock, or because there is some minute splinter between them, it is 
impossible to entirely overcome the widening of the intermalleolar 
space. 

Various forms of apparatus have been devised for maintaining the 
broken ends in contact. 

Boyer used two lateral splints, the outer one reaching a little be- 
yond the foot, while the inner one came down only to the level of 
the internal malleolus. 

Sir Charles Bell applied along the outer side of the leg and foot an 
angular splint, properly padded, and laid the leg on its outer surface, 
in a state of semiflexion. Sir A. Cooper employed two such curved 
splints, one on each side, and advised keeping the great toe on a line 
with the patella. 

Dupuytren states the indications otherwise; he recommends "car- 
rying the foot inward, the tibia being pushed outward, the lower 
fragment of the fibula raised, separated from the tibia, and in the 

* See my Journal de Chirurgie, 1843, p. 341. 
42 



658 A TREATISE ON FRACTURES. 

same direction with the upper portion of the bone." His apparatus 
consisted of a pad about twenty-seven inches long by three or four 
in width and about three in thickness ; a firm splint, seventeen inches 
long by two or three wide; and two bandages five or six yards long. 
The pad, bent upon itself so as to form a wedge, was applied on the 
inside of the limb, its base below, bearing upon the internal mal- 
leolus but not reaching beyond it, its edge above, over the internal 
tuberosity; over this pad was placed the splint, which should reach 
about three inches beyond the inner edge of the foot ; and both splint 
and pad were fastened to the limb with the first bandage. The free 
portion of the splint, thus separated by a considerable interval from 
the foot, served as & point d'appui for drawing the foot inward ; and 
with this view the second bandage, having been first fixed by turns 
around the splint, was carried alternately over the instep and heel, 
embracing the splint and each of these parts in turns of greater or 
less firmness, which formed a figure-of-8 by crossing one another 
over the splint. As to the rest, Dupuytren, like Sir Charles Bell 
and Sir Astley Cooper, laid the leg on its outer surface, in the semi- 
flexed position. 

M. Maisonneuve has remarked that this apparatus, drawing in- 
ward upon the point of the foot more powerfully than upon the heel, 
would answer the purpose completely in fractures by abduction, if it 
were not liable to become relaxed. He therefore employs it merely 
as a means of support for the dextrinated bandage. The reduction 
being made, and the foot somewhat forcibly adducted, he envelopes 
the foot and leg in a roller five or six yards long, soaked with dex- 
trine, putting a good many turns about the seat of the fracture. 
Over this he applies Dupuytren's apparatus, to keep the foot in 
proper position until the dextrinated bandage is dried; after which 
the latter is sufficient, and the other may be left off as useless. 

Now in order to judge between these different forms of apparatus, 
it is necessary to define precisely the indications. When reduction 
is made, we have simply to keep the fragments pressed together, so 
that they cannot slip. Boyer's splints exert indeed some pressure 
over the outer malleolus, but do not give sufficient support to the 
inner. That of Sir Charles Bell has the same defect; that of Sir 
Astley Cooper presses perhaps too uniformly over the whole outer 
face of the leg, to overcome a separation at all obstinate of the lower 
fragment; still, it must not be forgotten that the author obtained 
complete success with it in his own person. Dupuytren's splint 
tends to tilt outward the upper end of the lower fragment; it would 
be suitable at most only in fractures by abduction, as was remarked 
by M. Maisonneuve; and would certainly do great harm in such 
fractures as are shown in Figs. 95 and 96. Lastly, M. Maisonneuve's 
dextrinated bandage affords all the advantages of Dupuytren's splint, 
with greater solidity; although until it has dried, it is affected by the 



A TREATISE OX FRACTURES. 659 

unavoidable relaxation of the latter, and the forced adduction of the 
foot is, to say the least, useless. 

There are some fractures in which the displacement is so slight as 
to be easily reduced, and as to remain thus, so to speak, of its own 
accord; here the simplest apparatus will suffice. Nevertheless, in 
order to make the double pressure on the fragments with greater 
firmness, I apply along the inner surface of the limb a pad, folded 
like that of Dupuytren; on the other side, another pad, whose greatest 
thickness is over the astragalus and external malleolus; supporting 
the whole by two lateral splints reaching below the sole of the foot. 
This apparatus might also be used to keep a dextrinated bandage 
firm until it became dry. 

But I have met with cases in which the displacement was so obsti- 
nate as to reappear instantly on the cessation of pressure with the 
fingers upon the fragments; this pressure, to be efficient, needing to 
be quite firm. I have tried the flexed position, the two splints, Du- 
puytren's apparatus, the dextrinated bandage ; nothing answered the 
purpose. I have finally employed plaster, running a mould around 
the limb; it constitutes in these cases an invaluable resource. The 
rules for its application have already been sufficiently set forth; 
there only remain certain precautions to be specially noticed here. 
The limb should rest on its posterior surface, the knee moderately 
flexed, the foot raised at a right angle and perfectly vertical. Re- 
duction, being made, is kept up by the thumb of an assistant firmly 
applied over the outer malleolus, another assistant pressing in the 
opposite direction over the inner one. The plaster is now to be run, 
the assistants maintaining their pressure until its solidification is 
complete. The openings thus left may be filled up with the surplus 
plaster, or may be left unstopped without any inconvenience re- 
sulting. 

Fractures of the fibula, without displacement, unite perfectly in 
about thirty days. When the displacement is such as to endanger 
the solidity of the tibio-tarsal articulation, it will be prudent to keep 
the apparatus in place for thirty-five or forty days. 

§ IV. — Fractures just above the Malleoli. 

I apply this name to a fracture hardly alluded to in the books, 
which is located about an inch above the tibio-tarsal articulation, and 
which may or may not run into the joint. Sometimes it eon 
a nearly transverse division of both bones ; M. Ph. Boyer met 
with one immediately above the articulating surface of the tibia ; it 
is stated that there was no more bone between it and the articular 
cartilage than was absolutely essential to preserve the joint intact.* 

* Additions to the fifth edition of Boyer's Traite des Maladies Chirurgicales, 
etc. 



660 A TREATISE ON FRACTURES. 

At other times the fracture is more irregular, with wide serrations; 
the lower fragment of the tibia may itself be broken into several 
pieces, and as it were crushed; Figs. 91 and 92 present a very fine 
example of this. In some cases it is the fibula, the inner malleolus, 
and the anterior or posterior half of the tibia which are divided; I 
have published an account of a fracture obliquely separating the pos- 
terior half of the tibia, and involving also both malleoli;* this will be 
again referred to in connection with luxations of the foot. Fig. 93 
represents one of the other variety, that is to say, a triple fracture 
of the fibula, of the inner malleolus and of the anterior half of the 
tibia. Lastly, the tibia may be broken obliquely through its entire 
thickness, the fibula giving way at a point much higher up. It is 
evident therefore that these fractures assume various forms. 

Their causes also differ greatly. I have seen a case produced by 
the passage of a heavily loaded wagon over the lower part of the leg. 
According to M. Ph. Boyer, the most common cause is a fall on the 
ground, the injured leg coming under the other, and thus sustaining 
the whole weight of the body. For my own part, it is mainly by 
falls from a great height, as from a second or third story, that I have 
seen these fractures to occur ; the person alighting on the foot turned 
to one side or the other, or perhaps directly upon the heel; in Fig. 
93, the posterior portion of the calcaneum is seen to be broken, 
leaving no doubt as to the fall having been sustained in this way. 

Sometimes there is no displacement, or if there is any it is in the 
thickness of the bone, and is corrected without much difficulty. 
M. Ph. Boyer made a perfect cure of a fracture with considerable 
transverse displacement, in an old man of seventy, in the space of 
forty days. The treatment is here extremely simple; two lateral 
splints are sufficient, and after the subsidence of the swelling, which 
is always quite marked, the dextrinated bandage may be employed 
with perfect safety. 

But there are other and much more troublesome displacements, in 
which the lower fragment forms an angle with the upper, so that 
all the phenomena of a tibio-tarsal dislocation are presented. Thus 
in the case represented in Fig. 91, the foot was turned inward, as in 
luxation inward; the fibula, broken nearly at the same level as the 
tibia, distended the integuments by the angle between its fragments. 
I have seen one case in which the foot was turned outward, the 
fibula torn from the tibia below, and the fracture far above, just 
below its head. Lastly, the before-mentioned separation of the pos- 
terior portion of the tibia was attended with luxation of the foot 
outward and backward. 

The diagnosis is sometimes in such cases quite difficult, at least as 
regards the direction of the fracture, and all the accompanying ap- 
pearances. When the foot is strongly twisted inward or outward, we 

* Gazette Mtdicale, 1832, p. 647. 



A TREATISE OX FRACTURES. 661 

may be led to suspect luxation, especially if the parts are masked by* 
the swelling; if otherwise, we can generally obviate any mistake by 
examination and measurement. 

The prognosis is really serious, and more so by reason of the in- 
jury to the articulation, and the difficulties in the way of reduction. 
Stiffening of the joint is always to be dreaded; and sometimes the 
limb can only be saved at the expense of disagreeable deformity. If 
the lesion is complicated by a wound laying open the joint, the 
danger is essentially increased; and if at the same time the lower 
fragment is crushed, immediate amputation is almost the sole course 
available to us. 

One or two cases will perhaps give a still more correct idea of the 
gravity of this fracture. 

A woman forty-eight years old, in descending a staircase, twisted 
her foot outward, and fell; the whole weight of her body coming 
upon the leg, which was resting by its inner face on the ground. 
Hence there ensued a fracture just above the. malleoli, the foot being 
carried outward and backward. Reduction was performed, and splints 
applied. Next day there was swelling, with phlyctenre; the displace- 
ment was renewed, and Dupuytren employed his apparatus for frac- 
ture of the fibula, laying the leg, semiflexed, on its outer side. During 
the next few days the displacement tended to recur, and sloughs formed 
opposite the fracture; on the thirteenth day the state of the soft parts 
necessitated the removal of the apparatus; on the sixteenth it had to 
be reapplied, on account of the renewed displacement; abscesses began 
to appear ; to be brief, the patient came out from all this, after one 
hundred and eighty days of treatment, with a considerable stiffening 
of the ankle, deviation of the foot outward and backward, and pro- 
jection forward of the upper fragment of the tibia. 

A young soldier had his leg caught in a land-slide, and broken 

se to the malleoli, the foot being so much twisted outward that its 

external edge looked upward. The ordinary apparatus for fracture 

of the leg was applied, but without avail; the displacement recurred; 

-. sloughing, and exfoliation of bone supervened; eighteen 

months hardly sufficed for cicatrisation, and the patient could scarcely 

.11 to use his leg at the end of two years, the foot being as much 
turned outward as on the first day, and the fragments forming a very 
marked angle inward. " 

Andre* Pasta has related the case of a man of forty-five, who 
tained a compound fracture of the tibia near the ankle-joint. In- 
duction v but the next day it had to be abandoned on ac- 
count of genera] convulsions. The symptoms were thus gradually 
patient remained a cripple. f 

rioua such eases are, and how treatment will 

* Do puvtreu , .'/•' :<1 20. 

f Leveille. Xoucelle di 



662 A TREATISE ON FRACTURES. 

•sometimes fail even in the most skilful hands. It is above all im- 
portant to aim at allaying muscular spasm by poultices, bleeding, 
opium or ether if necessary, and by relaxed position, flexing the 
knee to any required extent. As to apparatus, the inefficiency of 
splints and bandages is evident from the foregoing cases; and I 
know of none which under such circumstances would answer so well 
as my screw, before described. 

[An excellent plan for the dressing of compound fractures, par- 
ticularly those of the leg, was devised by Dr. J. R. Barton of Phila- 
delphia; it consists in filling a fracture-box, such as was previously 
described, with bran; so as to form not only a bed but a covering 
for the limb. The extensive use of "Barton's bran dressing," 
throughout the United States, sufficiently attests its value. 

In Geddings' Baltimore 3Iedical and Surgical Journal for 1833, 
Dr. N. R. Smith published a description of a splint contrived by him, 
and intended for fractures either of the thigh or of the leg. This 
splint is now extensively known in the United States, under the 
name of its inventor; it is however more generally used for the leg 
than for the thigh. It is especially valuable in fractures seated very 
near the malleoli ; by the kindness of my friend Dr. Addinell Hew- 
son of this city, I have seen one such case in which no other appa- 
ratus could have answered the purpose so exactly. In the use of 
this splint, the principle of suspension is commonly adopted. 

An account of this splint, to be complete, would occupy too much 
space to be inserted here, but the article itself is generally kept on 
hand by instrument makers.] 

§ V. — Fractures of the Malleoli. 

These fractures would seem to me to be extremely rare, at least in 
an uncombined form, I have observed barely three or four cases; 
and M. Ph. Boyer, who states that he has seen a larger number, has 
probably met with them by favor of fortune. 

Sometimes they involve the outer malleolus, at the portion ad- 
joining the articular surface of the tibia; sometimes the inner one, 
and sometimes both at once. 

The outer malleolus is easily broken in the dead subject by violent 
adduction of the foot, and it was stated in the section on fractures of 
the fibula that neither Dupuytren nor M. Maisonneuve were able to 
obtain any others. The line of division is transverse, situated at or 
below the base of the process, or sometimes so low down that the 
injury is as it were merely a tearing off of the tip; the ensheathing 
fibrous tissues being unbroken, there is little or no displacement. 
Perhaps this want of displacement has sometimes caused these frac- 
tures to be mistaken for mere sprains; but the difference in the 
exact seat of the pain should serve to prevent such an error. If 



A TREATISE ON FRACTURES. 663 

there is any displacement, it is in the direction in which the foot is 
turned ; and M. Ph. Boyer claims in fact to have seen cases of this 
kind in which the foot was twisted somewhat inward. The simplest 
apparatus will always answer here. 

M. Nelaton has had an opportunity of observing a fracture of the 
external malleolus of an entirely different form ; it was oblique 
downward, inward and forward, thus separating only the posterior 
and outer part of the process ; it was attended with a dislocation of 
the astragalus, and was detected at the autopsy.* 

Fracture of the internal malleolus is more common, and presents 
itself under two forms. In the first, the fracture is transverse, and 
nearly on a level with the articular surface of the tibia; sometimes 
it is close to the point of the malleolus, which seems to be as it were 
torn off. This variety quite frequently complicates bad fractures of 
the fibula, and is generally the result of forcible abduction of the 
foot by a fall or a misstep. The fragment is commonly retained in 
place by the fibrous tissues investing it, and almost our only clue to the 
lesion is the pain. But at other times it is completely detached, and 
drawn down by the internal lateral ligament; there is then a per- 
ceptible separation between it and the rest of the bone, increased by 
abduction, and diminished by adduction of the foot, and the broken 
piece can be grasped and moved to and fro. Sometimes the cause is 
a direct one, such as the passage of a carriage-wheel over the mal- 
leolus, and there is at first no displacement; but on the patient at- 
tempting to get up and walk, the foot, having lost its support on the 
inner side, is apt to be turned outward ; hence there occurs a second- 
ary displacement, or even a fracture of the fibula, also secondary; 
Dupuytren's twelfth observation affords an instance of this. 

The second variety of this fracture is seated higher up, an inch or 
somewhat less from the hip of the malleolus; it separates this process 
from the rest of the bone by a division running obliquely downward 
and outward, and terminating almost invariably in the entering angle 
between the malleolus and the main articulating surface of the tibia. 
Fig. 01 represents a fracture of this kind complicating one just above 
the malleoli, and in Fig. 92 is shown the line of division of the 
articular surface. This injury would seem to be due generally to 
direct, but sometimes to indirect violence. I have recently seen an 
instance of its occurrence from the kick of a horse, in a little girl 
eight years old. Dr. Isaac Hays has seen a similar one in a man of 
sixty-five, who in an access of delirium jumped from a second-story 
window, alighting on a cellar-door fastened with a padlock; a small 
wound over the malleolus gave the idea that it had struck upon this 
padlock, the fracture resulting from the blow.f 

In the last-mentioned case, although the fragment was but slightly 

* Bulletin de la SocUU Anatornique, 1835, p. 38. 

f American Journal of the Med. Sciences, Aug., 1837, p. 535. 



664: A TREATISE ON FRACTURES. 

movable, its limits were exactly defined to the touch ; there was no 
tendency to inclination inward of the foot. In my little patient, on 
the contrary, the foot was somewhat turned inward; but there was 
no difficulty in making reduction, and by merely fixing the leg and 
foot between two lateral splints, a cure was effected without the 
slightest deformity. 

Lastly, both malleoli may be broken at once. M. Ph. Boyer 
claims to have seen a good many such cases ; according to him, they 
are always produced by forcible abduction or adduction of the foot, 
but more commonly the latter; and the false step made in slipping 
from a sidewalk is their most frequent cause. They may affect the 
malleoli at any point, from the base to the tip, sometimes with and 
sometimes without rupture of the periosteum ; in the former case the 
foot will be twisted either inward or outward, according to the par- 
ticular movement giving rise to the double fracture; but this dis- 
placement may be readily corrected. The malleoli seem further apart 
than in the sound limb ; the solution of continuity may be recognised 
by the touch, and our author remarks particularly that the patient can 
raise the foot up without the assistance even of his own hands. 
Pasteboard splints and a roller, and afterwards a starched or dextri- 
nated bandage, suffice to keep the fragments in position; at the end 
of forty or fifty days the patient is able to walk; but he should be 
directed to wear for some time a gaiter or a laced stocking. Some- 
times there remains rather more difficulty in walking than after other 
fractures of the leg; in other cases there is no difference. 

I have merely given M. Boyer's description, not having myself 
had an opportunity of seeing similar cases. I have indeed occasion- 
ally met with fracture of the inner malleolus together with one of 
the lower extremity of the fibula, as a consequence of falls, and Du- 
puytren obtained the same in his experiments with forcible abduc- 
tion of the foot. Most commonly there is then luxation; but I have 
treated one patient, thirty-four years of age, in whom there was no 
displacement of any kind; the fracture of the fibula was however 
above the malleolus. 

The swelling does not always permit us to ascertain the exact seat 
of the fracture, which after all is of no very great practical import- 
ance. The only case in which both malleoli have seemed to me to 
be broken, was that of a railroad employe'; he had the point of his 
foot entangled under a rail, when his heel was struck by a cross-tie 
thrown with great violence. The foot, being caught between these 
two forces, was preternaturally extended upon the leg; there was a 
sprain of the anterior part of the ankle, and rupture of both mal- 
leoli, as far as could be made out for the swelling. There was no 
displacement; I simply applied two lateral splints, taking care to 
keep the foot and leg at a right angle ; and the patient readily re- 
covered, having at the time of his discharge only a quite marked 
swelling of the ankle, and some stiffness of the joint. 



CHAPTER XIX. 



FRACTURES OF THE FOOT. 



These, like fractures of the hand, are much more frequently met 
with in men than in women: and they are mostly the result of direct 
violence, such as the fall of a heavy body, or powerful pressure of 
some kind. Falls on the feet here come under the head of direct 
causes, in regard to certain bones; thus I have several times seen 
most of the bones composing the tarsus broken by falls from a second 
or third story. This is indeed the most common cause of fracture 
of the tarsus; its slight projection securing it in great measure from 
the action of external forces. Ledran, however, reports a case in 
which it was crushed, without any displacement, in a coachman whose 
horse fell under him while galloping. M. Marjolin saw a still more 
curious case; it was that of a soldier, who, seeing a spent ball rolling 
along, tried to stop it by putting his foot upon it; such a ball, as is 
well known, retains for a long time a rotatory movement, and may 
even bound if touched; this did actually occur, and the tarsal bones 
were so crushed as to necessitate amputation.* In all cases in which 
nearly all the bones of the tarsus have been thus destroyed, either 
the patient has soon succumbed, or the removal of the foot has been 
requisite. I shall therefore delay no longer upon the subject. 

The fractures which we have to consider particularly are: (1) those 
of the astragalus; (2) those of the calcaneum; (8) those of the me- 
tatarsal bones; (4) those of the phalanges of the toes. 



§ I. — Fractures of the Astragalus. 

These are always the result of falls from a height, the person 
alighting on the feet; but there is this remarkable circumstance con- 
cerning them: that in cases of general crushing of the tarsal bones 
I have almost always found the astragalus intact, while at other times 
it seen stain the full effect of the fall, being the only bone 

which is fractured. 

. de Ckvrwgie, tome ii. p. 352; Marjolin, Cows dt Paiho- 
look I 



(66$) 



666 A TREATISE ON FRACTURES. 

Nothing is more variable than the direction of this fracture. M. 
Tavignot met with one extending antero-posteriorly through the body 
of the bone, the neck of which presented also an incomplete trans- 
verse fracture.* I have in my collection a specimen of a very dif- 
ferent form, the bone being divided almost transversely into two 
portions, one anterior and the other posterior. Lonsdale saw the 
astragalus split in two or three directions. Lastly, Rumsey com- 
municated to Sir A. Cooper a still more singular variety, the bone 
being separated in a nearly horizontal direction, one fragment being 
superior and the other inferior. 

In all these cases the existence of the lesion has been only disco- 
vered by dissection. In Lonsdale's, it had not even been suspected 
during life; there was no displacement, and the swelling occurring 
around the joint had been attributed to a severe sprain; but the 
inflammation ran so high as to destroy life on the twelfth day. 
M. Rognetta says that he twice saw simple fractures of the astragalus, 
without any displacement, or any injury of the soft parts; at the 
instant of the accident, or even after the swelling had subsided, he 
detected the lesion by the sensation imparted to the touch, like that 
of several nuts in a bag. The fracture must therefore have been 
multiple. Both these patients having recovered readily, the diag- 
nosis could not be verified by dissection. f 

[It may be doubted whether the multiple character of these frac- 
tures was proved by the sensation alluded to, since it is well known 
how completely the most delicate touch may be deceived; and espe- 
cially where effusion into the articular cavity would increase the 
chances of error.] 

Sometimes one of the fragments projects outward; and as in that 
case it is separated from its ligaments, the lesion is commonly con- 
sidered in connection with luxations of the bone. But I know of no 
other case analogous to that seen by Rumsey, in which the upper frag- 
ment, retaining its relation to the bones of the leg, protruded with 
them through a large wound. Rumsey disarticulated and removed 
this piece, thus converting the injury into a tibio-tarsal luxation; and 
this is doubtless the reason why Sir A. Cooper has as it were mis- 
placed this curious case in his account of these luxations. The pa- 
tient recovered in the space of three months. 



§ II. — Fractures of the Calcaneum. 

There are two very distinct varieties of these fractures: rupture 
by muscular action, and crushing. 

Until the publication of my memoir concerning this latter injury, 

* Bulletin de la Soc. Anatomique, 1843, p. 170. 
f Archiv. G6n. de Me'decine, 1833, tome iii, p, 498. 



A TREATISE ON FRACTURES. 667 

the former was the only one recognised ; it is described by all the 
classic authors ; and what is curious, not one of those who thus de- 
scribed it pretended to have ever seen it. It may therefore be safely 
presumed that imagination played a more prominent part than reality 
did in their descriptions. The cases were indeed of rare occurrence; 
I have myself been able to collect only eight, and those mostly very 
incomplete. 

The first was published by Garengeot, in 1720. A man fractured 
his calcaneum by falling into a sewer ; Poncelet, being called to see 
him twenty-four hours afterwards, opened a little swelling due to ex- 
travasation of blood, saw at the bottom of this the posterior fractured 
portion of the bone, and finding that the piece was not firm, cut the 
tendo-Achillis which held it, and extracted it. The patient is said 
to have recovered, and to have walked as well as ever.* 

Some writers, with Heister at their head, have asserted that in the 
case just alluded to the tendo-Achillis was divided with a view of 
favoring the approximation of the fragments ; but of this it is evi- 
dent that Poncelet never dreamed. According to Garengeot's ac- 
count, we may consider it to have been a fracture by crushing, such 
as that in Fig. 93 ; but J. L. Petit, to whom Poncelet showed the 
says expressly that it was the result of retraction of the tendo- 
Achillis. 

J. L. Petit, in a memoir read before the Academie des Sciences, in 
1722. cites an analogous instance; u Madame la pre'sidente de Bois- 
he, "made a false step, and retracted the tendo-Achillis 
rcibly a- to break the heel-bone." 

After this come two cases observed by Desault, one of which is 
reported by Richerand, and the other by Bichat. In each, the frac- 
ture was due to a fall from a height, the toes striking first. These 
were the only ones bequeathed to science by the eighteenth century, 
and Bojer knew of no others. Since then there have been published 
in succession one case by Bottentuit, one by Assalini, one by M. Lis- 
franc, and one by Custance.f 

If we seek to derive some conclusions from these cases, we find in 
the first place as to the causes, that the fracture was twice the result 
of a false .-top ; once by the upsetting of a wagon, the heel being 
caught between it and the ground; five times by a fall from a height, 
alighting on the feet. The special circumstance of the fall being on 
the toes is only noted in Default's two cat 

The fracture is alwa; behind the astragalus. But is the 

bori" broken vertically, so that the two inferior tuberosities are both 
Comprised in the detached piece? or is any other direction assumed! 

■ ■ • 

1//. /"//,/. ti.mr' \\iv. ]>. .'577 : In/male 

gia; L sfranc, Archil . Gen. cU M <</<< me, tome .wi. p. L09 ; ( Instance, 
tome xxi. p. 124 



668 A TREATISE ON FRACTURES. 

or, finally, is there only a tearing off of the portion of bone into 
which is inserted the tendo-Achillis ? We have no positive data on 
this subject. In Poncelet's case the fracture occupied the posterior 
part of the bone ; Richerand also speaks of a posterior fragment ; 
Bichat calls it exterior, which is very vague ; but it should be re- 
marked that none of these three writers had witnessed the cases. 
Bottentuit says that the bone was broken at its upper extremity ; 
M. Lisfranc speaks also of a fracture of the upper and posterior 
portion; but Custance states distinctly that the posterior part of the 
bone was involved, immediately below the point of insertion of the 
tendo-Achillis. 

The fracture is almost always single, that is to say, free from 
splinters ; M. Lisfranc' s case forms the only exception to this rule. 

The detached fragment is drawn more or less backward and upward 
by the muscles connected with it, by the contraction of which it was 
torn off. The extent of this displacement is very variable ; it was 
almost nothing in Poncelet's case, and in Bottentuit's it amounted to 
only half a finger's-breadth ; in that of Custance, on the contrary, 
it was very great ; the fragment was removed five inches from its 
natural position, or as is subsequently explained, from the bottom of 
the heel. This interval would of course be increased by extension 
of the leg and flexion of the foot, and diminished by flexion of the 
leg and extension of the foot. Desault and Assalini succeeded in 
obtaining perfect contact, by means of the latter position. Neither 
Lisfranc nor Custance were so fortunate; but it is not said that they 
attended to the position, and some of the details of their cases would 
seem to indicate the contrary. 

In one case, the skin was ruptured as well as the bone ; a circum- 
stance not clearly accounted for. In three there was severe pain, 
and in one of these there was inflammation ending in gangrene. It 
should be remarked that these symptoms are not mentioned in con- 
nection with those cases in which the limb was put in a rational 
posture. 

The fragments once placed in contact, consolidation takes place 
without difficulty. It was completed by -the forty-seventh day in one 
of Desault's patients ; in the woman treated by Lisfranc, the de- 
tached portion was at first reunited by fibrous tissue, but in the end 
it became immovable, which would apparently prove the connection 
to be bony. Even without such union, the consequences are less 
grave than we might be led to suppose; Poncelet's patient walked 
none the worse, although the fragment in his case had been removed ; 
and Custance's, in spite of the great separation, reduced hardly half 
an inch by contraction of the cicatrix, could walk five years after- 
wards without pain or apparent inconvenience, and wearing an ordi- 
nary shoe ; in a word, as well as ever. Some exaggeration may be 
suspected in this account ; but we may infer at least that the gait. 



A TREATISE OX FRACTURES. 669 

even in the most unfavorable cases, is not seriously and permanently 
affected. 

The diagnosis would seem never to have presented any very great 
difficulty. The separation of the fragments when the leg is extended, 
their approximation, and the crepitus rendered perceptible by it, 
vrhen the leg is flexed, and lastly the free mobility of the detached 
portion, can hardly leave any room for doubt. 

The prognosis, judging from the cases known, is by no means 
grave. 

The entire treatment is based upon two indications : the first, and 
by far the most important, is to keep the foot extended and the leg 
flexed ; the second, hitherto neglected, is to make direct pressure 
upon the fragments, so as to keep them in contact and hasten con- 
solidation. 

To meet the first indication, recourse may be had to any of the 
contrivances for rupture of the tendo-Achillis. J. L. Petit used at 
first a sort of uniting bandage, made with pieces of a common roller ; 
Desault added a compress, to be placed transversely above the upper 
fragment, and to aid in bringing it downward. Such pressure would 
have rather the effect of pushing it forward among the deep muscles 
of the leg ; besides which, the bandage would have the serious disad- 
vantage of being apt to relax. 

For this reason Petit himself abandoned it. He fitted the injured 
foot with a slipper, to the heel of which was attached a long strap; 
this strap passed upward to be wound upon a windlass fixed at the 
back of a leather knee-piece, embracing the limb above and below 
the knee. Monro simplified this apparatus, fastening the strap by 
means of a buckle to a sort of half-gaiter laced around the calf of 
the leg : but by this plan the advantage of flexion of the knee was 
lost. "Thillaye'conceived the happier thought of having a firm band 
pass upward from the heel of a shoe of leather or muslin, to be 
buckled to the back of a garter or circular band surrounding the limb 
above the knee. 

I shall say nothing of the splint applied by Monro over the front 
of the leg and back of the foot, so as to keep the foot extended, 
except that he was himself unable to tolerate it. 

Thillaye's apparatus is certainly the simplest and the most efficient 
of all, the sole of the shoe being made very solid, so that the tors 
shall not be subjected to undue pressure when the strap is tightened. 
Boyer, indeed, objects that if the fracture were vertical the sole would 
have the effect of pushing up the fragment, which should be drawn 
down, rtdfl is true in the case Bupposed, and it would then be neces- 
sary to have the sole somewhat bent, BO as not to bear upon I lie heel 
Or we might, with still greater simplicity, keep the leg very Btronely 
flexed on the thigh, by passing a folded handkerchief beneath the 
sole of the foot, crossing its ends over the instep, and then making it 



C70 A TREATISE ON FRACTURES. 

surround the leg and thigh, knotting it in front of the latter. In all 
cases the leg should be laid upon its side. 

As regards the second indication, it is perfectly fulfilled by pass- 
ing a strip of plaster around the heel, and crossing the ends over the 
instep ; and there is no need of dwelling upon it further. 

Another form of this fracture, much more common than the pre- 
ceding, is that by crushing. It had been completely lost sight of at 
the time when my memoir was published ; but since then the instances 
of it have multiplied, and all surgeons have learned to recognise it.* 

Almost the only cause producing this lesion is falling on the heel ; 
M. Huguier, however, has shown me one case in which it was due to 
lateral pressure, the integuments remaining intact; it had not been 
diagnosed, and was discovered only by dissection. A fall upon the 
heel may occur under various conditions; it may be that only the 
posterior portion is struck, and then the lesion will affect it alone, as 
in Fig. 93; or the heel may come down almost flat, which is most 
generally the case. Lastly, both heels may strike at once, and both 
bones be broken; of this I have seen one instance, and another has 
been reported by M. Yoillemier. 

If a calcaneum so fractured be carefully examined, it will be seen 
that the crushing may take place in different degrees. Fig. 99 re- 
presents it as it occurred from a fall out of a window which was 
only breast-high; the upper face of the bone is shown. A horizontal 
fracture, beginning at the base of the greater articular facette, has 
first divided it into two portions, one above the other; the anterior 
end of the upper of these is driven into the spongy tissue of the 
other to a depth of four or five millimetres. This upper fragment 
is again divided into two by an antero-posterior fracture ; and these 
two fresh fragments are separated in front by an interval of four or 
five millimetres. The inner one, which alone was movable, gave rise 
during life to indistinct crepitation; all the others, including those 
of the anterior part, those of the inner face and those of the lower 
face of the bone, were so retained in place, either by the investing 
fibrous tissues or by their mutual interlocking, that it was impossible 
to elicit from them the slightest crepitus. 

On the whole, the bone was crushed from above downward, and 
was diminished in thickness; at the same time its fragments were 
separated so as to increase its width. Thus at the posterior edge of 
its larger articulating facette, its thickness was only four centimetres, 
and on a level with its lesser tuberosity its width was fifty- five milli- 
metres. 

Figs. 98 and 100 represent a larger calcaneum than the preceding, 
crushed by a fall of seven or eight yards. The thickness of the bone 

* Malgaigne, Mimoire sur la fracture par icrasement du calcaneum; Jour- 
nal de Chirurgie, Jan., 1843 ; ibid., 1843, pp. 63, 92, 376 ; and 1845, p. 154. 



A TREATISE ON FRACTURES. 671 

at the posterior edge of the larger articulating facette was reduced 
to three centimetres ; its width opposite the lesser tuberosity was 
sixty-five millimetres. The corresponding bone of the other foot, 
crushed by the same fall, presented almost exactly similar alterations 
in its thickness and width. 

The symptoms are, in the first place pain of such severity as to 
prevent the patient from walking; although if the crushing is but 
slight, he may be able to limp along a little. This is what took place 
in the subject of Fig. 99, who fell but a short distance, and in M. B6- 
ringuier's patient, who fell from a height of about six feet. Almost 
simultaneously with the pain there comes on swelling, involving both 
malleoli, the instep, a portion of the back of the foot, the sides of 
the foot below the malleoli, and a portion of the sole of the foot; 
what is remarkable, the heel and the region of the tendo-Achillis 
are exempt. This swelling so completely masks the deformity, that 
an inexperienced eye would think the foot free from injury; and it 
is so marked over the malleoli, especially the inner one, as to almost 
irresistibly attract attention to that part. But over the malleoli, as 
well as on the back of the foot, it is soft and compressible, while be- 
low the inner malleolus it rests on an abnormal bony prominence, 
formed by the lesser apophysis of the calcaneum. The ecchymosis, 
at first scarcely perceptible, becomes more marked after the lapse of 
some days ; it may cover the lower third of the leg, but is chiefly 
situated below the malleoli. Here too the most pain is caused by 
pressure, at first at the inner side, then at the back of the heel; 
sometimes over the malleoli themselves. Crepitation is obscure, and 
often wanting; the best way to elicit it is by moving the calcaneum 
in different directions, and especially by rotating it, or by carrying 
it from side to side. The two characteristic deformities are: the 
increased width of the bone, perceptible by close inspection, but 
especially to the touch, below and a little in front of the inner mal- 
leolus ; and the falling of the arch of the foot, sometimes evident to 
the eye, and at any rate felt by the hand when the soft parts at the 
back of the foot are pressed downward. This sinking in may also 
be verified by measurement; thus ML Beringuier, comparing the two 
sides in regard to the distance between the apex of the outer mal- 
leolus and the sloping part of the heel, found that on the injured 
side it was lessened by one centimetre. The same practitioner 
has likewise observed the heel to be elongated backward ; by 
measuring the foot from the heel to the great toe, he detected an in- 
erease in length of one-third of an inch; and a tape, carried around 
the heel from one malleolus to the other. Bhowed also an exci 
half an inch. Still, in another patient, M. More* sought in rain to 
discover any sign of this elongation; possibly because the crushing 
was less severe.* 

* Beringuier, Journal de Chirurgie, 1843, p. 376 ; More, ibid., 1845, p. 1 54 



672 A TREATISE ON FRACTURES. 

The first time that this fracture came under my notice, I mistook 
it for a fracture of the fibula, without displacement, and complicated 
with a sprain. The same error was committed in Voillemier's case; 
and M. Bonnet of Lyons was himself misled in the same way, being, 
like myself, only undeceived by the dissection of the part. It may 
be avoided by noting carefully the point where pressure is painful, 
by using the means alluded to for eliciting crepitus, and above all by 
observing, both by the touch and by measurement, the projection in- 
ward of the calcaneum and the sinking in of the arch of the foot. 

Even after the calcaneum is known to be broken, there may re- 
main some doubt as to the complications, — some suspicion, for 
instance, of fracture of the malleoli or of the astragalus. I would 
say in the first place, that such complications are very rare ; fracture 
of the astragalus, indeed, has never been to my knowledge seen in 
this connection;* and besides, we may press directly on the head of 
this bone, after the example of M. More, and ascertain whether such 
pressure develops either crepitation or pain. 

The course of these fractures is sometimes unfavorably influenced 
by cerebral symptoms, resulting from the concussion of the fall it- 
self. Some patients complain of extremely acute pains at the seat 
of injury, persisting for four or five days, or even longer; this is 
particularly the case with those who have been subjected to traction 
on the foot in order to correct the displacement, and is probably due 
to malposition of some splinter. 

Consolidation takes place slowly. Fig. 99 shows a fractured cal- 
caneum at the thirteenth day; those in Figs. 98 and 100 were at the 
forty-eighth; in Fig. 98 we observe a total absence of reparative 
action on the exterior, and in Fig. 100 the callus in the interior is 
seen still to present numerous lacunae. It is therefore a good while 
before the free use of the limb is recovered. M. More"s patient be- 
gan to walk at the end of six weeks ; but for more than a year he 
was subject, after any excess in walking, to tearing pains in the foot, 
accompanied by heat and swelling. M. Beringuier's patient still 
had, after two months, pain in walking over an uneven surface; 
M. Voillemier's, who had had both calcanea broken, was under treat- 
ment for seven or eight months before he could walk, with the aid of 
a stick, for twenty minutes. 

The ultimate results have been investigated in two patients; in 
one by M. More, after the lapse of about fifteen months, and in the 
other by M. Voillemier, after thirteen years. The former could walk 
more than twenty miles a day, but he limped a little, instinctively 
tending to put the foot down by its middle part or sole. If, indeed, 
he rested his weight upon the heel, he felt as if the ground were 

* [I have recently seen two dried preparations of fractures involving both the 
calcaneum and astragalus ; one of them was caused by a railroad injury, and the 
other, I believe, by a fall upon the heel.] 



A TREATISE OX FRACTURES. 673 

giving way ; if on the contrary he hore upon his toes, it gave him 
great pain in the tibio-tarsal joint, which still remained a good deal 
stiffened. Yoillemier's patient had by degrees learned to walk quite 
easily, and for a good while, without limping, by means of high- 
heeled shoes. His heels being thus raised, the feet could be flexed 
to a useful degree; but he had to be careful not to carry this too far; 
since, for example, if the foot were set flat upon the ground, and 
there were under its anterior part a projecting body, even of no 
greater volume than a nut, the excessive flexion would give rise to 
intense pain in the ankle-joint. For the same reason, while he could 
still jump from below upward, it was almost impossible for him to 
jump down the distance of one yard. The functions of the foot 
were therefore pretty nearly restored, though they were still by no 
means in the normal condition. On the whole, there is left after the 
cure of this fracture more or less flatness of the foot, with stiffening 
of the tibio-tarsal articulation, or rather perhaps of those of the 
astragalus with the scaphoid and calcaneum. 

The prognosis, it is evident, is not without gravity, which is pro- 
portionate to the amount of crushing. 

The treatment is extremely simple. It is unsafe to try to lessen 
the flattening of the bone by drawing down the heel, and therefore 
the only indication is to keep the foot at rest and in good position, 
until consolidation is complete. I make use at first of two lateral 
splints, as in fractures of the leg, in order to watch the progress of 
the swelling, and if necessary to combat it. This having subsided, 
it is well to employ an immovable apparatus, enabling the patient to 
get up and go about on crutches. He should wear this apparatus 
for at least forty-five days, after which the joints of the foot may be 
exercised, to avoid subsequent stiffening ; but it is safer for him to 
wait till the end of the second month before trying to put the foot to 
ground, and then care should be taken to make up as much as pos- 
sible for the flattening of the heel, by thickening the heel of the 
shoe to a proportionate extent. 



§ III. — Fractures of the Metatarsal Bones. 

These fractures are very rare; scarcely three or four cases occurred 
in the Hotel-Dieu during the eleven years which we have studied ; 
and judging from this very small number of facts, the fourth and 
fifth bones are more frequently involved thai the others, doubtless 
by reason of their greater slenderness. The lesion is almost always 
due to direct violence, and hence is attended witli contusion, or even 
with a wound; sometimes there is a real crushing; lastly, -M. J'. B& 
rard has seen the fifth metatarsal fractured near its posterior ex- 
tremity in consequence of a fall on the feet. 

43 



674 A TREATISE ON FRACTURES. 

The nature of the injury is recognised by the local pain, by the 
projection upward of the posterior fragment, and by the crepitation. 
If the last-named sign is not perceived by pressing with the finger 
over the supposed seat of fracture, it may be produced by grasping 
the corresponding toe and moving it in different directions. 

Not unfrequently the diagnosis can be only a probable one, all the 
phenomena being absent except the local pain. It is quite rare that 
even the displacement is well-marked, the sound bones serving not 
only as a partial protection from external violence, but also subse- 
quently acting as splints. But when two or three bones at a time 
are involved, this defence is taken away, and the displacement may 
be extreme. I recently had to treat a career, who was thrown down 
under his vehicle, and had the three middle metatarsal bones broken 
by the wheel passing over them. The anterior fragments were very 
greatly depressed ; there was a lacerated wound on the back of the foot, 
and the inflammation was most intense. It was therefore impossible 
to remedy the displacement, and indeed the saving of the foot could 
hardly be hoped for. The patient recovered, and could plant his 
foot very firmly on the ground, but the great projection of the upper 
fragments at the back of the foot obliged him to wear a shoe of a 
particular shape. 

For fracture without displacement, rest is almost the only remedy, 
and a lightly applied immovable apparatus will enable the patient to 
walk about as soon as the inflammation has subsided. Any displace- 
ment that may occur should be corrected by the same contrivances 
as those for fractures of the metacarpus, and thirty days at most 
will suffice for consolidation. The instance above mentioned shows 
that even the worst cases should not be too readily given up as hope- 
less. Delamotte met with similar success in a man who had had the 
first four metatarsals divided by a blow with an axe. Union was 
complete by the fortieth day, but the patient was not allowed to walk 
until the end of the second month ; and the foot became so firm that 
when he stamped on the ground alternately with it and the sound 
one, they could not be distinguished from one another.* 



§ IV. — Fractures of the Phalanges of the Toes. 

These commonly occur by crushing, and are only called fractures 
when the destruction of the tissues is not very considerable; hence 
their apparent infrequency, in consulting our figures from the H6tel- 
Dieu. Only ten are recorded for the eleven years, and in seven of 
these ten the great toe was the one involved. All the patients were 
men. 

* Delamotte, Traite de Chirurgie, obs. 384. 



A TREATISE OX FRACTURES. 675 

I have six times seen fracture of the first phalanx of the great 
toe, always resulting from the fall of some heavy body, but never at- 
tended with an external wound. There was no appreciable displace- 
ment; the pain first directed my attention to the part, and the crepi- 
tation, always readily produced, gave certainty to the diagnosis. A 
small splint at the plantar face, fastened by two strips of adhesive 
plaster, answered the purpose in each case; only it is important to 
pad the splint sufficiently, and to put a somewhat thicker compress 
under the second than under the first phalanx, so as to preserve the 
normal form of the toe. Consolidation takes place in twenty-five or 
thirty days. 

As for fractures of the other toes, I have never seen them except 
with such destruction of the soft parts as to necessitate either the 
removal of the anterior fragment or the amputation of the toe. In 
the smaller toes this operation is not very dangerous ; in the great 
toe it involves much more of a risk, since among forty-three such 
amputations for injuries, done in the Parisian hospitals from 1836 to 
1841. seven deaths occurred. This is an imperative reason for limit- 
ing the extent of the amputation, when it becomes necessary, as much 
as possible; the removal of the last phalanx, for example, involves 
hardly any danger at all. 



BIBLIOGRAPHICAL TABLE. 



WORKS OX FRACTURES GENERALLY. 

Among the ancients, Hippocrates, Celsus, Oribasius, Galen, Paulus iEgineta, 
Fabricius of Acquapendente, and Fabricius Hildanus, are the best authori- 
ties, and may be readily consulted by means of translations, if not in the 
originals. 

In Pare's Works will also be found much that is valuable on this subject. 

M. Verduc. — La maniere de guerir les fractures et les luxations par le moyen 

des bandages. Paris, 1689. 
J. L. Petit. — L'art de guerir les maladies des os. Paris, 1705. 
Duverney. — Traite des maladies des os. 
G. C. Reichel. — Dissertatio inauguralis de epiphysium abassium diaphysi di- 

ductione. Lipsiae, 1759. 
White. — Cases in Surgery. London, 1770. 
Pott. — Chirurgical Works, vol. i. London, 1771. 
Joh.v H.UDOE. — Some Strictures on the Treatment of Compound Fractures. 

London, 1779. 
Benjamin Bell. — A System of Surgery. Edinburgh, 1787. 
Walteb Weldon. — Observations Physiological and Chirurgical, on Compound 

Fractures. Southampton, 1794. 
John Aitken. — Essays on Fractures and Luxations. London, 1 
P.J. Desault. — A Treatise on Fractures, Luxations, and other affections of the 

Bones. Edited by Xav. Bichat, Translated from the French by I 

Caldwell, M.D. Philadelphia L805. 
Desault. — rEnvres Chirurgicales, ou expose* de la Doctrine et de la Pratique 

de P. J. Desault. Par Xavier Bichat Paris, 1 B 1 '■>. 

43* (077) 



678 BIBLIOGRAPHICAL TABLE. 

Boyer. — Trait6 des Maladies Chirurgicales, et des operations qui leur convien- 

nent. Par M. le Baron Boyer. Paris, 1814-1818. 
Roux. — Relation d'un Yoyage fait a Londres en 1814, ou Parallele de la Chi- 

rurgie Angloise avec la Chirurgie Francoise. Paris, 1815. 

F. D. R. Fayod. — Dissertation inaugurate sur les Fractures en general. 

Paris, 1819. 

Lisfranc. — A memoir on the diagnostic signs afforded by the Stethoscope in 
Fractures, etc. Translated from the French by J. R. Alcock. London, 
1827. 

Joseph Amesbury. — Syllabus of Surgical Lectures on the Nature and Treat- 
ment of Fractures, etc. London, 1827. 

A. L. Richter. — Theoretisch-praktisches Handbuch der Lehre von den Bruchen 
und Yerrenkungen der Knocken. Berlin, 1828. 
Plates, etc., to the above. Folio. 

S. D. Gross. — The Anatomy, Physiology and Diseases of the Bones and Joints. 
Philadelphia, 1830. 

Stephen L. Hammick. — Practical Remarks on Fractures, etc. London, 1830. 

Joseph Amesbury. — Practical Remarks on the Nature and Treatment of Frac- 
tures of the Trunk and Extremities. Plates and Cases. London, 1830. 

G. W. Hind. — A Series of Twenty Plates Illustrating the Causes of Displace- 

ment in the Yarious Fractures of the Bones of the Extremities. Folio. 

London, 1835. 
Sir, Charles Bell. — Institutes of Surgery. Edinburgh, 1838. 
Edward F. Lonsdale. — A Practical Treatise on Fractures. London, 1838. 
Mayor. — Nouveau Systeme de Deligation Chirurgicale. Paris, 1838. 
Seutin. — Du bandage amidonne, ou Recueil de toutes les pieces composees sur 

ce bandage, etc. Brussels, 1840. 
Wilkinson King. — Article on Fractures, in the Cyclopedia of Practical Surgery. 

London, 1841. 
Xelaton. — Elemens de Pathologie Chirurgicale, vol. i. Paris, 1844. 
Dupuytren. — On the Injuries and Diseases of the Bones ; being Selections from 

the Clinical Lectures of Baron Dupuytren. Translated and edited by 

F. Le Gros Clark. London, 1847. 
Sargent. — On Bandaging and other Operations of Minor Surgery. Philadel- 
phia, 1848. 
Edward Stanley, F.R.S. — Illustrations of the Effects of Disease and Injury of 

the Bones. Folio. London, 1849. 
Gibson. — Institutes and Practice of Surgery, vol. i. Philadelphia, 1850. 
H. H. Smith.— Minor Surgery, etc. Philadelphia, 1856. 
Hamilton. — Reports on Deformities after Fractures. Transactions of Am. 

Med. Association for 1855, 1856 and 1857. 



BIBLIOGRAPHICAL TABLE. 679 



WORK? OX SPECIAL FRACTURES. 

Joannes T. Adolph. — Programma, quo capsam Petitianam pluribus cruris com- 
plicate fracti casibus aptaudaui propouit Joannes T. Adolpk. Helmstadii, 
1760. 

F. A. Ceenotte. — Dissertatio sistens casum subluxationis vertebrae dorsi cum 
fractura complicate, etc. Argentorati, 1761. 

Petri Camper. — Dissertatio de fractura patella? et olecrani ; figuris illustrata. 
Hagae Ccmitum, 1789. 

John Sheldon. — An Essay on the Fracture of the Patella, with Observations on 
the Fracture of the Olecranon. London, 1789. 

Chas. B. Trye. — Illustrations of some of the Injuries to which the Lower Limbs 
are exposed. London, 1802. 

Johx Parker. — An Inaugural Dissertation on Fractures of the Leg. Philadel- 
phia, 1804. 

Sir James Earle. F.R.S. — A Letter containing some Observations on Frac- 
tures of the Lower Limbs, etc. London, 1807. 

Dupuytrex. — Des Fractures ou Courbures des os des Enfans. Bulletin de la 
Faculte" de Medecine. Paris, 1811. 

Charles Bell. — Observations on Injuries of the Spine and of the Thigh Bone. 
London, 1824 

Amesbury. — Observations on the Nature and Treatment of Fractures of the 
Upper Third of the Thigh Bone, and on Fractures of long standing. Lon- 
don, 1829, 

Guthrie. — Clinical Lectures on Compound Fractures of the Extremities. Lon- 
don. 

Sir Astley Cooper. — A Treatise on Dislocations, and on Fractures of the 
Joints. London, 1842. 

R W. Smith. — A Treatise on Fractures in the vicinity of Joints, etc. Dublin, 
1847. 

Thomas Callaway. — On Dislocations and Fractures of the Clavicle and 
Shoulder-joint. London, 1849. 

Ferdinand Martin. — Essai BUI une nouvelle methodede traitement des frac- 
tures du col et du corps du femur. Paris, 1851. 

M. niEiELsiiEiM. — Observation d'une fracture de l'apophyse zygomatique (di- 
recte) et de Tarcade du trou sous-orbitaire, (indirecte.) Paris, 1853. 

Gamgee.— On the Relative Merits of the Different Methods of Treating Fractures 
of the Lower Limbs. London, 1856. 



680 BIBLIOGRAPHICAL TABLE. 



Gunshot Fractures. 

Larrey. — Memoirs of Military Surgery, etc. Translated by R W. Hall, M.D. 

Baltimore, 1814. 
Clinique Chirurgicale. Paris, 1829. 
Hennen. — Principles of Military Surgery. London, 1829. 
Guthrie. — Commentaries on the Surgery of the War in Portugal, Spain, France, 

and the Netherlands, from 1808 to 1815. London, 1853. 
Saurel. — Memoire sur les fractures des membres par armes a feu. Montpellier, 

1856. 

Ununited Fractures. 

Buchanan. — Essay on Diseased Joints and the Non-union of Fractures, etc. 
London, 1828. 

G. "VY. Norris. — On the Occurrence of Non-union after Fractures, its Causes 
and Treatment. Hays' Am. Journal for January, 1842. 

Brainart^. — On a New Method of Treating Ununited Fractures, etc. Prize Es- 
say presented to the Am. Med. Association, 1854. [Trans, of Assoc.) 

H. H. Smith. — On the Treatment of Ununited Fracture by means of Artificial 
Limbs. Hays' Am. Journal for January, 1855. 

Repair of Fractures. 

Kceler. — Experimenta circa regenerationem ossium. Gottingae, 1786. 

Bichat. — Anatomie Generale. 4 vols. Paris, 1801. 

G. Breschet. — Recherches historiques et experimentales sur la formation du 

cal. Paris, 1819. 
Lebert. — De la formation du cal. Paris, 1844. 
Yoetsch. — Die Heilung der Knochenbrliche. Heidelberg, 1847. 
Paget. — Lectures on Surgical Pathology. London, 1853. 

This table might be indefinitely extended, were reference made to even the 
most important of the articles contained in journals, reviews, etc., on different 
points connected with the subject. It may however be well to mention that 
such articles are to be found in the American Journal of the Medical Sciences, 
the British and Foreign Medico- Chirurgical Review, the Edinburgh Medical 
and Surgical Journal, the Midland Quarterly Journal, the London Lancet, 
the* Medico- Chirurgical Transactions, Guy's Hospital Reports, etc., etc. 



I N D E X. 



Adhesive plaster in counter-extension, 
585. 
in extension, 585. 
in fractures of the patella, 617. 
in fractures of the leg, 040. 
Age, influence of on fractures generally, 

IS. 
Amputation, primary, cases requiring, 

secondary, 287. 

consecutive. 287. 
Anchylosis, false. 209. 
Aneurism, complicating fractures, 229. 

Bache's extending screw, 586. 
Barton's bandage for fracture of the jaw, 
316. 
operation for fracture of vertebrae 

with distortion, 313. 
bran dressing, 662. 
fracture of the radius, 496. 
Bond's splint for fractures of the lower 

end of the radius, 497. 
Boyer's argument against the use of 
bandages, 171. 

Callus, correction of, - 

rupture of. - 

section of, 272. 

resection of, 273. 

pain u 

exuberance of. 2 

fungous growths from, 282. 
Cancer, influence of on fracture 
Cartilages, sterno-costal, fractured by 
muscular violence, 059. 

by a blow, 300. 



Causes, predisposing, 17. 

determining, 34. 
Cervix femoris, fractures of, discussion 
in regard to, 532. 

Rodet's experiments upon, 534. 

bony union in, 544. 

Mussey's cases of, 545. 
Clavicle, fracture of, indications in, 
384. 

Fox's apparatus for, 395. 

Levis's apparatus for, 395. 
Comminuted fractures, 74. 
Complicated fractures, 78. 
Condyles of femur, cases of fracture of, 

593. 
Contusion as a sign of fracture, 83. 
Cracking as a symptom of fracture, 80. 

Deformity as a sign of fracture, 87. 
Delirium, traumatic, 236. 
Dieffenbach's operation for ununited frac- 
ture, 258. 
Diet, influence of upon union, 122. 
Displacement, varieties of, 88. 
Dressings employed by Hippocrates. 168. 

Ecchymosis, 83. 

Effects of motion, experiments on, 211. 
Erysipelas, effects of, upon union, 125, 
186. 
in compound fractures, 234. 
Extension and counter-extension, 167. 

apparatuses for, 196. 
Extension by adhesive plaster, in the 
thigh, 585. 
in the leg, 640. 
Extraction of splinters, 218. 

081 



682 



INDEX. 



Femur, gunshot fractures of, Saurel's 

cases, 597. 
Fissures, 42. 
Fistulse, 233. 
Fracture-box, 638. 

Gangrene from premature pressure, 205. 

Gibson's splints for fractured thigh, 587. 

Gilbert, adhesive plaster in counter-ex- 
tension, 585. 

Gout, influence of on fractures generally, 
25. 

Hamilton, fractures of hyoid bone, 327. 

of laryngeal cartilages, 330. 
Hartshorne, (Joseph and Henry,) splints 

for fractured thigh, 587. 
Horner's splints for fracture of the thigh, 

585. 
Humerus, anatomical and surgical neck 
of, 415. 
splints for, 422, 436, 441. 
internal condyle, fracture of by mus- 
cular action, 452. 
Hydatids, a cause of non-union, Dupuy- 
tren's case, 242. 

Incomplete fractures, 42. 

properly so-called, 48. 
Inflammation, 231. 
Insane patients, restraint of, 203. 
Intra-uterine fractures, 39. 

Jackson's case of partial fracture of cer- 
vix femoris, 552. 
Joints, effects upon, 99, 116. 

Lente's cases of fracture of vertebrae, 

341. 
Ligature of arteries, effect of upon union, 
125. 
of bone, 225, 252. 
Loss of power, a symptom of fracture, 
82. 

Measurement, mode of, etc., 138. 
Mobility, preternatural, a symptom of 
fracture, 85. * 



Multiple fractures, 73. 
Muscular spasm, 164, 230. 
resection in, 166. 

Necrosis, 233. 

Neill, extension and counter-extension, 

585. 
Non-union, local causes of, 126. 

Oblique fractures, 67. 

Obliquity of fractures, effect of upon 

union, 126. 
Olecranon, fractures of, treated by semi- 
flexion, 461. 
by extension, 462. 
by adhesive strips, 465. 

Pain as a symptom of fracture, 81. 
Paralysis, effect of upon union, 125. 
Pare's account of his accident, 143, 217. 
Patella, the author's apparatus for frac- 
ture of, 622. 
Perforations, 58. 
Perineal band, Coates', 585. 
Physick's case of non-union in lower 
jaw, 322. 

splints for fracture of the thigh, 
584. 

gaiter, 585. 
Pregnancy, effect of upon union, 123. 
Pseudarthroses, varieties of, 136. 

operations for, 246. 

rubbing, 246. 

acupuncture, 248. 

seton, 249. 

ligature, 252. 

resection, 253. 

scraping, 256. 

Dieffenbach's operation for, 258. 

cases of, from New York Hospital, 
261. 

Watson's cases, referred to, 261. 

Rachitis, influence of, 30. 

numerous fractures in, 31. 
Radius, fracture of, by muscular action, 
483. 

indications in fracture of, 492. 



683 



Radius, Lave on's fracture of, 496. 
Refracture, artificial. 269. 

cases of, '271. 
Ribs, adhesive plaster in fractures of. 3-34. 



Smith, (Nathan R.,) splint for fracture 

of thigh or leg. 662. 
Splintered fractures, oO. 
Splints, various forms and materials for, 
172. 
Bond's, 407. 
Splint-cloth, 176. 
Sternum, fractures of during labor, 

366. 
Suppuration in compound fractures, 220, 



Suture of bone, 225. 

Swelling, as a symptom of fracture, 

84. 
Syphilis, influence of, 20. 



Scapula, cases of fracture of, 402, 413. 

Scrofula, influence of, 29. 

Scurvy, general, 25. 

Seasons, influence of on fractures gene- 
rally, 21. 

Semipronation in fractures of the fore- 
arm, 476. 

Separations of epiphyses, 60. 

of fragments, hindering union. 127. 

Serrated fractures, 64. 

Seutin*s apparatus, 170. 

Sex, influence of on fractures generally, : Tetanus, 235. 

20. Tibia, Malgaigne's screw apparatus for 

Skeleton, predisposition to fracture in fracture of, 642. 

parts of, 22. ; Transverse fractures, 63. 

Sloughing over the sacrum. 236. Treatment, improper, a cause of non- 

Smith, (Henry H.,) plan for treating un- union, 120. 

united fracture, 214. 
cervix femoris, 545. Yallet's lit dc mine, 146. 

Smith, (Nathan R.,) anterior splint for Vertebras, fracture of, with distortion, 
fracture of the thigh, 588. successfully treated, 344. 



PLATE I. 





EXPLANATIONS OF THE FIGURES. 



PLATE I. 



Fig. 1.— Fissure of the Amur. (Museum at Val-de-GrAce.)—This bone belonged to a very large man; it 
measured forty-four centimetres [about sixteen inches] from the top of the head to the inner condyle: 

and in its upper portion the wall ol" the shaft was five to eight millimetres [one-sixth to one-fourth 
Of an inch] in thickness. On its anterior face is seen a long vertical fissure, irregular here and there, hut 
single, and thirteen centimetres [four and one-third inches] in length. Immediately below this is an- 
other one. very small, about one-third of an inch long: above it are two others, each an inch or so in 
length, and another is situated a little less than two inches above the knee-joint. 

On the inner face of the bone, in its lower third, there is another fissure an inch Ions: on the outer 
face, near the linea aspera. there is a series of five fissures, altogether about sixteen centimetres [five or 
six inches] in length. Those of the anterior face only are represented. 

There is nowhere found any mark of external violence: nor can any history be obtained of this sin- 
gular specimen. 

The bone being sawed open from above downward, the largest fissure was plainly seen to Involve the 
whole thickness of the wall: no sign of the others could be detected interiorly. 

Fig. 2. — Incompl-f. fracture of the ulna, produced on the dead subject. — 1 am now in possession of a 
similar fracture of the same bone, recognised during life, and rendered certain by post-morti m dissection. 

Fig. Z.— Perforation of the upper extremity of the right humerus by a ball. (Museum at. Val-de-Qr&ce.) 
— The bone is viewed upon its outer and somewhat posterior aspect, the epicondyle looking forward and 
somewhat to the right. 

A ball of ordinary size has penetrated the neck of the bone, close to the lower attachment of the cap- 
sular ligament, forming quite a regular cavity, without a trace of any other fracture. The hall was not 
extracted, but was found upon the dead body long after the time of the injury: it had preserved its form. 
except a small fragment which was found intrusted in the upper wall of the cavity in the bone. 

This cavity, which is seen somewhat obliquely in the figure, was twenty-eight millimetres in \ertical 
diameter at its orifice, and more than forty within: twenty-five millimetres in transverse diameter at its 
orifice, including the notch, and thirty within. It occupied all but about three to five lnillinui 
thickness of the cervix humeri, the anterior wall of which is seen to be perforated by a small orifice. 
The interior of the cavity was quite regular, bounded throughout by areolar or spongy bone, and \\ ith- 
out communication with the medullary canal. Its bas-foiv), so to speak, was one centimetre below the 
lower edge of the orifice, and the ball, resting on this floor, filled only about one-third of the whole 
caviry. 

be regretted that we have no information as to the date or course of the injury, nor a- to the 
condition of the soft parts upon dissection. Was this large excavation made at the first, by reason of 
the rotary motion of the ball, or did it result from a slow process of absorption of the bone around the 
ball, by a sort of vital dilatation? I incline to the latter opinion, chiefly because of the regularity of the 
inner surface of the caviry. 

Fig. 4-. — Disjunction of the superior epiphysis of the humerus. (Musit Dupuytren, No. 91.) — If. Cham- 
pion's specimen, described at | 

Fig. 5. — ObliqitA fracturt of the humerus, produced upon the dead subject. 

Fig. 6. — S re of Oief mur,produced upon the dead subject. — Compare with Figs. ~ 

Fig. t. — Fracture of the tibia, with a runei form splinter, combined with a double fracture of Iht fibula. 
— A woman aged 50, had her right leg caught nnder a cask of wine, and sustained a fracture with a 
lacerated wound, exposing the lower fragment of the tibia to the extent of over an inch. This Lower 
fragment could not be kept in place at all: (I had not then contrfvi d my screw apparatus;) granulations 
tg up around the denuded portion, which became necrosed; about the fifteenth day the symp- 
toms of purulent absorption set in. attended with colliquative diarrhoea, and the patient died on the 
twentieth day. 

The fibula i- seen to be broken in two places; the middle fragment riding up upon the Inn 

•r one. but carried somewhat to the outside of the inferior; a reddish tissue studded with lit- 
tle bony points shows the progress of the work of repair. 

The tibia prea snts two pointed fragments, with a wedge-like splinter detached from its inner surface. 

and displaced outward into the intero--eou- space. Tie' whole substance of this splinter is penetrated by 

small triangular necrosed hit ju-t at its summit. The npper fragment of the tibia is 

idged with mi'.' ind both the inner and outer face presenl little bony prominences 

of new formation, showing that the repair was begun. On tie- contrary the whole of the denuded por- 
tion of the lower fragment is hard, white, killed; it- <■•>.. . and have a worm-eaten appear' 
ance; th rdering it is hollowed out to the depth of one or two millimetres. This hollow- 
was fjlh-d up by a -ofr. reddish membrane, which was prolonged nnder tie- edge of the necrosed portion, 
and which during life had tie- usual aspect of granulations, it- adhesion to the subjacent bonj tissue 
slight; that which i- seen naked in the figure was reddish, but rery hard; and p 
• y longitudinal strip'- of hone, sending out -mall lateral branches to one another, and 
by ridges of a deeper red <-<'\>>r. i-.^Uy cut with a knife. They resembled tie- normal fibres of tie- hone, 
isolated and rendered prominent by the development of line vessels in their Int I ■ i 
down, the fragment resumed its normal thickness; hut it was studded with very a\ 

.•v. giving it a deep t 

■ a gunshot fracture of 

I l mte r - are wh I 
off" from the thickness of the wall of th- shaft. In three of them, — the two Lai lie-sized 

sternal face of the bone i- easily reoognisi d. hardly at all affected bj 
h trri- tl fissure, not involving it- entire thicks 



PLATE II. 

Fig. 9.— Fractures of the ribs of the right side. (Musee Dupuytren, No. 8, a.) — These fractures, result- 
ing from violent pressure, involve eight ribs, from the second to the ninth inclusive. They are all sin- 
gle, that is, each rib is broken at but one point ; there is overlapping in most of them ; and the narrowing 
of the lower intercostal spaces is such that the sixth, seventh and eighth ribs are soldered together. The 
specimen is described at page 352. 

Fig. 10. — Incomplete fracture of the fifth rib, with complete fractures of the fourth and sixth, on the 
right side. — These lesions resulted from a fall against the arm of a sofa; the third and seventh ribs were 
broken at the same time. Death ensued on the third day. The inner aspect of the specimen is repre- 
sented ; the three fractures are seated at nearly the same distance from the cartilages, but the upper and 
lower one present a prominence inward of the posterior fragment, while in the middle one, involving 
only the external table, the internal table is seen bent inward, forming an angular prominence. See 
page 347. 

Figs. 11 and 12. — Fractures of the sternum, found in a dead subject by M. Huguier. — In Fig. 11 the 
anterior aspect of the bone is presented, showing the irregularity of the edge of the lower fragment, 
which has passed up in front of the other. Fig. 12 represents a vertical section of the bone; the over- 
lapping is seen to be only partial, and accompanied by angular displacement forward, which affects 
chiefly the lower fragment. 



PLATE II. 




PLATE III. 





PLATE III. 

Fig. 13.— Fracture of the nose, with marked lateral displacement of the lower fragment. (Muse\ Du- 
puytren. No. 39.) — A full description of this specimen is given at page 293. 

Fig. 14. — Recent fracture of the lover jaw.— This specimen was taken from a man who threw himself 
Gram a height of two stories, and -was instantly killed. The fracture is oblique forward ami outward; 
the posterior fragment, bevelled off at the expense of its inner face, has overlapped the anterior to a con- 
siderable extent: an overlapping undoubtedly favored by the absence of the teeth in the tbi mer. 1 have 
made a notch in the bone in order to ascertain the state of the inferior dental nerve: it proved to he per- 
fectly intact, the overlapping having prevented its stretching, and the resulting separation 6f the frag- 
ments, its being pressed upon. 

FlB. 15.— Recent double fracture of the lower jaw.— The middle fragment is formed almost entirety 
from the left half of the bone. The posterior fracture runs Obliquely outward ami forward, as in the pre- 
ceding case, and the displacement is also similar: but the anterior fracture, besides its very apparent 
Obliquity downward and inward, divided the hone in its thickness in such a way that the middle frag- 
ment is at its upper part bevelled at the expense of its inner table, and at its lower part, at the expense 
of its outer table. It was driven backward by the external violence, and moreover pulled downward by 
the muscles. Reduction could not be effected: the bevelled edge of the righl half of the bone riding over 
that of the middle fragment, prevented the latter from being drawn forward. See pages 309 and 318. 

Fie. 16. — Double fracture of the lower jaw. with depression of tin middle fragment, and vicious <-<>i>- 
solidation. {Musee Dupuytren. No. 53.) — this fracture was caused by a charge of small shot tired from a 
gun: the middle fragment is driven backward and drawn downward, as in the preceding case : but lure 
the fragment has also undergone such a change of position, that its lower bolder is inclined forward, 
and its outer face looks almost directly upward: consolidation has taken place, giving permanence to 
these displacements, as well as to a marked approximation of the left posterior to the right and anterior 
fragment. 

In this case the dental nerve was ruptured, and its canal obliterated at the scat of fracture. See page 310. 

Pie. 17. — Recent fracture of the left clavicle, icith great obliquity. — The bone is represented with its 
upper face inclined somewhat forward, so as to show the direction of the fracture, forward and outward. 
The patient died of other lesions, almost immediately after the accident. 

- — Fracture near the middle of the clavicle, with angular projection and p.v udartiu-oxis. i .l/v.sv', 

■ i. Nb.50.) — The line of fracture seems to have been inward and backward. The Sternal frag- 
ment is carried upward and forward, the acromial downward and backward: there is a very marked 
overlapping: terms which express the three usual displacements. But one great difference between this 
specimen and the others is. that there lias been no bony union, or in other words, a false joint has been 
formed: another is the strange shape of the bone, which is such that, even putting the two fragm ni- end 
to end, we should not have a normal clavicle. This is because the sternal fragment, instead of being 
nearly straight, or forming a gentle curve from one extremity to the other, presents an exaggerated con- 
vexity forward, and posteriorly a hollow half an inch in depth. Its outer extremity would se< m to have 
lually bent backward bj Hie motions of the false joint, or perhaps its anterior promin 
: 30 that in place of a projection forward of this fragment alone, we have an obtuse angle formed 
by the two. 

However this may b-. b --i<Ts the three chief displacements mentioned, the acromial fragment is low- 
ered at its outer end. and perhaps its posterior border is somewhat higher than the anterior. 

pie. 19. — theacromio-l extremity. (Musee Dupuytren, No.55.) — This frac- 

ture would seem to have been somewhat oblique backward and inward : it has <ii\ ided the bone internal 
to the insertion of the coraco-clavicular ligaments. The acromial fragment has descended below the 
other by more than two centimetres ; it is also carried backward, and the anterior angle of the sterna] 
fragment forms a very marked projection forward. Lastly, the overlapping exceeds two centimetres, 
and the bono is very much shortened. A thick callus, pierced from above downward with a smooth hole. 

- the posterior edge of the acromial fragment with the body of the bont : it extends about an 
inch along the latter. 

—Double fracture of the clavicle. [Musee Dupuytren, No. 65.) — One of these fractal 
inch from tie- sternal end of the bone, seems to have been oblique outward and backward \ the 
- quently slipped down somewhat, and very much forward, its point projecting 
nearly two centimetres in front of the other. The second fracture is seated about an inch from the acro- 
mial '*nd: it seems to have been oblique downward and outward, so that the outer fragment has ridden 

hat over the Other, without notably deviating either forward or backward. The greater part of 

the coraco-clavicular ligament was -till adherent to the inner, or more strictlj speaking to the middle 
fragment. Perhaps there is a Blight obliquity of the acromial fragment downward and inward. All this 
is evidently dm- to the obliquity of the fracture. 

rda fracture near the sternum, I should state that there le only one other example of it in the 
4:. this fracture i- single, but a- it presents the same phenomena, I have net 
had it represented. 

fto.21.— rthe acromial extremity This specimen was pre- 

sented without hist i 1 '' fracture seems to luv hat oblique back- 

ward and inward, and" to have divided the b >nejus1 at the junction of it- body with the acromial portion, 
:.r angle of which is -till part of the outer fragment ; it i- therefore just inside the Inni 
►-clavicular ligaments. The outer fragment has descended about one centimetre ; but it Is also 

carried backward and inward. -o that the inner one i- entirely in front of it. making a very marked pro* 
i shortening the bone by more than one centimetre. A broad, tl.it. triangular callus, unite* 
mial fragment to the body of the bone posteriorly, and i- prolonged inward for three centime- 
rig the latter. 
II , as in Fig. 19, there is seen a triple displacement; the lowering of the acromial fragment, the 
overlapping, and the projection forward of the sternal fragment. Tin- latter is about the same in both 
-: the two other displacements are in tl much less marked. 11 should 1 

the acromial fragment has descended en ma <. remaining parallel to the other: while In Fig, 
somewhat oblique, it- outer end being a little lower than tie- oth< r. 



TLATE IV. 

22 and 23. — Multiple fractures of the scapula, and fracture of the cervix humeri.— Specimen 
y M. foillemier. The scapula is broken in its body, in its nock, across the glenoid cavity, in 
the acromion and in the coracoid process. 

(1.) The fracture of the body of Vie scapula separatee nearly the whole of the inferior third Of the 
bone. It describes an arc convex superiorly, so that the upper edge of the tower fragment is also con- 
Fiy. 23.) The upper fragment is divided into two parts by another fracture, which hae de- 
tached the whole outer edge and glenoid cavity from the rest of the bone, following the line of the cervix : 
another quite voluminous fragment, comprising the upper half vf the cervix and the summit of the 
glenoid cavity, has been separated both from the preceding piece and from the base of the ooraooid pro- 
- itself, with a small portion of the upper edge, has been separated from the body of the 
bone. There are thus in all four large fragments separated from the body of tin 1 bone, not counting 
the point of the coracoid process and of the acromion, to which allusion will be made directly. 
On the one hand the two pieces first named are carried outward, leaving quite a Larg 
them and the body of the bone: it is a displacement by separation, hitherto not pointed <>ut in this 
. reality. It might at first be thought that the interspace was increased by the 
Of which is however seen firmly united. But a 
careful study of the specimen shows that the salient angles of each fragment ■ My to (he 

the others, and that, but for several masses of caHns which hare been thrown oat, they 
>ne another without any apparent losBofsube two fragments are there- 

fore drawn outward, and the body of the bone I ilted a little npWard and toward, so as to 

favor th ition. 

The lower fragment is in consequence carried cons ide rably within and in front of the outer (rae,whicfe 
_'J and 23.) and at the same rime it has ridden up by nearly !«• 
centimetres. Besides this triple displacement, seen in the drawing, there Is a fourth which could not he 
;. The outer fragment is tilted backward at its • that, if prolonged to the 

level of the inferior angle of the bone, it would be nearly six centimetres distant from the (attar. Tin- 
angle and the fragment to which it belbl - arly in the - 1: 
tion with the i of the bone. 

On the other hand, the outer fragment, comprising the greater part of the glenoid e.-ivity. pi 
ward on- tree at it- upp - H also with the o i at, which 

seems tilted backward, so that a marked interval is Left between the 

• up by an intermediate bit, which seems wedged in between them posteriorly, 
and which moreover aids in k- I fragment apart from the bod] of the bone. 

- the multiple character of this fracture, in which the displacements are so numerous and varied 
that neither pen nor pencil can completely set forth their dlflei ugh hac 

been sail z ■• •■ some idi a of them. 

<- lOme thick:. 

and the side of the bone, and about the triple ftantare of the eervtx. 1 : It on the 

r th" frnjrrne! •- 

otter near the middle -how- that the cBfn cutty lay not in fee t! 
. >>nt in the interposition of th-- periosteum. 

me, seated ju-t behind the articulation with t), 
iter fragment has easts 
millimetre- more than the other, from whieh it i- th- n 

the same time depressed about one millimetre, but wtt i IncHaatton oi ii- point. The 

upper e*!;: — -how roughness*^ d- 

could not fill up the interspace between I 



PLATE IV. — CONTINUED. 

(3.) The fracture of the coracoid process is irregular, and seated about two and a half centimetres from 
its point; one little bit of it was divided into two, which were at one side united by solid callus; very 
slight traces only of fibrous tissue could be detected elsewhere. 

(4.) Fracture of the cervix humeri. Let us note first that the humerus displays a transverse fissure of 
its cartilage, (Fig. 23;) another one, vertical in its direction, is not represented in the cut. This latter 
hardly involved more than the cartilage; but the other penetrated to a depth of nearly an inch. 

The [surgical] neck of the humerus is also fractured obliquely, the division beginning at the inner 
Mde. an inch from the head of the bone, and running downward and outward to terminate two and one- 
third inches from the summit of the greater tuberosity. The specimen shows several serrations and 
small splinters, not to be distinguished in the cut from the rudiments of the callus ; the displacement 
has taken place somewhat inward, the inner wall of the superior fragment being caught in the medul- 
lary canal of the inferior. This canal shows no traces of callus; that of the upper fragment contains 
some small bony stalactites. The debris of the callus, where the fibrous tissue has been eaten away by 
insects, may be also seen; and an osseous formation of notable size, resembling the callus, at the place of 
attachment of the deltoid, about four and a half inches below the seat of fracture, is prolonged up to the 
latter point by small deposits of callus. In fact, the callus is traceable for a distance of six centimetres 
downward from the seat of fracture. 

Fig. 24. — Transverse fractures of the body and lower angle of the scapula. — This specimen was taken 
from a young epileptic at Bicetre, who a long time before his death sustained a fall upon his back. It 
is described fully at page 403. 

Fig. 25. — Fracture of the acromion. (Musee Dupuytren, No. 67.) — This specimen came from Desaulfs 
collection. The fracture is a straight one ; commencing posteriorly just behind the scapulo-clavicular 
articulation, three centimetres from the extremity of the acromion, and terminating in front at the cor- 
responding point. The outer fragment is inclined downward, separating from the other above only, as 
if the periosteum at the under surface had resisted the violence which ruptured that at the upper. The 
fracture was one of long standing, its upper edges being apparently heightened by the formation of an 
abnormal bony crest, particularly prominent upon the scapular fragment. No consolidation had oc- 
curred, nor even union by fibrous tissue; the fractured surfaces seemed worn, as if by rubbing upon one 
another. The clavicle seemed rotated downward and forward, following the fragment to which it was 
attached. 

In the same Museum there is another fracture of the acromion, (No. 68,) presented by M. Cruveilhier. 
The one before mentioned had evidently belonged to a robust man; this seems to hare been that of a 
woman. In other respects the two cases seem almost exactly similar; both fractures affect the right 
scapula; both have the same direction; both are of long standing, ununited, and have at their upper 
edges bony crests, especially marked upon the inner fragment. The one last named, however, has one 
peculiarity: while both fragments are on a level by their upper faces, the outer one is three or four mil- 
limetres below the other interiorly; which has led the compiler of the Musee Dupuytren to think that 
the tvjo surfaces of the fracture had overlapped one another in their entire extent. This was very im- 
portant, as involving a displacement quite different from that observed in the other specimen. Now I 
have measured the fractured surfaces with the utmost care, and find, posteriorly, that 

The scapular fragment is 7 millimetres in thickness. 

The clavicular fragment is 12 " " 

And in front, where the thickness is not yet lessened by the bevelling off at the outer edge of the 
acromion, 

The scapular fragment is 5 millimetres in thickness. 

The clavicular fragment is 9 " " 

Hence there has been no overlapping of the surfaces; the two fragments, as has been stated, have re- 
mained on a level by their upper faces, and the extraordinary prominence of the clavicular fragment 
below is due to hypertrophy, by which its thickness has been nearly doubled, — a very curious phe- 
nomenon, sometimes met with elsewhere, especially in ununited fractures of the elbow. 



PLATE 17. 




PLATE V. 






PLATE V. 

Wsb. 26.— Recent intra-capsufar fracture. — The left humerus is here Been, In its posterior aspect The 

tuberosities, separated both from the shaft and from the head of the hone, are divided into three frag- 
ment- aud tilted outward. The head, detached at the anatomical neck, is partially crashed; the 
diaphysis. drawn up. is hi contact with the lower part of the glenoid cavity. The capsule remained in- 
tact : it was divided in the preparation so as to display the fracture. See page 427. 

27. — An analogous specimen to the preceding. (Museum at Valrde-Orace.) — The right humerus of 
an I'M woman, stripped of its soft parts, is seen by its anterior face. The head, separated from the 

diaphysis. is tilted outward; it has been detached also from the tuberosities, except a very small portion. 
which has remained adherent to them. The tuberosities are in their turn separated from the diaphj si-. 
turned outward, and the greater one divided into two portions by a vertical fracture not shown in the 
drawing. - 

m and 29. — Intra-capstdar fracture, of long standing. (Museum "f Valde-Or&ce.)—In 

i- s sen by it- anterior and inner face: in Fig. 29, it is turned around so that the head look • '<• 
th- ri_rht. 

- only at Fig. 23, th- fracture would ba thought to divide aim '-t vertically the head and out c 
portion of the shaft, the outer fragment, comprising the two tuberosities, rising up a little above the 
ether. The section shown in Fig. 29 will however correct Che mistaken idea thus ■•' 

walls "f the diaphysis as far as the commencement of tie- epiphysis, proving the fracture at 
this point t" h iv • be n transvers -. an 1 all the portion " i onstitul ■ the outer fragment t" 

j an exuberant callus. The two tuberosities, detached both from tie- diaphysifl and from the 
inner part "f tie- head of the bone, have b sen push d outward hut not n ■ iriy so much ;>- in Figs. 20 and 
27: the head itself, displaced in the Bame direction, has lost some of its usual prominence; above maj t> 
seen a portion of its compacl wail, which has penetrated the spongy texture ol theoutei 
the lower and inner part, on the contrary, the ft , have c uued n i other displacement than 

a alight flexion, while neither without. | Fig. 28,) d « within. | Fig. 2d,) do any traces of < ill u 

nomena are common enough in epiphyseal separations; weahall notice them in the two follow- 
in l also iri a fracture at the lower extremity of th'- radius, Fig. St. 

I .-, of this 

bone. Ti; inward of the head of the bom iring its present with its 

normal outline, the latter being dotted out in th ■ drawing; tie- Dallas at tie- inferior portion is quite 

voluminous, and when tfa tii tl fracture, 

i illy, on the C .ntrary. there i- ri . trie of Callus, the b i it thi- 

point. The frequent occurrence of this phenomenon in epiphyseal disjunctions I Ij alluded 

tin •- fear and Ive from th" bott taadol 



PLATE VI. 

Figs. 31 and 32. — Fracture of the neck of the humerus, with more marked displacement. — In Figs. 26, 
27, 28 and 29, we have given the name of intra-capsular fractures to such as extended also heyond the 
limits of the capsule. Here the fracture penetrates somewhat beneath the capsule, as is seen by the 
irregularities of the head of the bone, (Fig. 31;) but this may be considered a mere epiphenomenon, the 
specimen having the essential characters of an extra-capsular fracture. See page 425. 

In these two figures we see, especially by means of the dotted lines, how much the head and tuberosi- 
ties have been inclined downward and inward. The inner wall of the diaphysis penetrates quite deeply 
into the spongy texture of the head ; the outer wall, on the contrary, shows no line of demarcation, as 
if, as was remarked in regard t the preceding specimens, it had undergone a mere flexion. 

The walls of the diaphysis a*e seen to be thinned, and the medullary canal to be filled up with spongy 
tissue. The man had been subjected to an amputation in the continuity of the humerus, a long time 
before his death. 

Figs. 33 and 34. — Fracture of the neck of the humerus, with complete disjunction of the fragments. — 
See page 417. 

Fig. 35. — Double fracture of the shaft of the humerus. — The upper fragment is displaced outward from 
the middle one, and this latter in front of the lower one. The callus is irregular and beset with rough- 
nesses. See Fig. 26. 



PLATE VI. 












/ 3 l 



PLATE VII. 



36 msam ^ 




PLATE VII. 

.—Double fracturt of the humerus.— This is the same bone as tint nipua mill nl in /•'/./. 35, seen 
.. The callus is seen to be exuberant, and spongy throughout: besides which, the fragments of 

the shaft are channeled by abnormal Burasee, attesting the fact of au inflammation of their tissue. This 

fact serves to explain the irregularity and abundance of the callus. 

re, with separation of a splinter from fheanterx bone. — The lower 

is carried backward, forming with the other an angle salient posteriorly. The callns is 
in spite of the contact of the two fragments in front, the compact tissue remains ununited. 

* — Fracture running obliquely downward and outward; displacement in the same direction* 

- specimen was presented bj Professor Lassus. — The direction of the 

fracture is so evident in the specimen, that it needs no comment. The npper fragment is carried forward 

and inward, the lower outward and backward: I may add that the two fragments, in contact below, are 

mi a very acute angle opening upward, filled up by callus, but betrayed by a 

rtical groove. 

The humerus, 1 - - b Lis thirty-three centimetres in length; the end of the upper fragment 

■ Lbow-joint, that of the lower has ridden up twelve cen- 

tomoard, inward, mid u tft&t forwar <■ •. N ». v 7. 

the line of divisi ginst the jomt; m consequence of its esurse, the lower frag- 

ment has ridden up oatward and forward, making with the upper one an angle salient in both these 
direction- - rm r fragment projects strongly in front of the inner face of the 1 air. 

■,-</ and backward. (Muee\ Dupuytren, No. 83.) — Pre- 
.-. — The bone i- so represented ;<- to show it- outer bee, with a part also of its 

posterior face, and especially the great sigmoid cavity. This being undersl 1. it may be seen at onco 

that the lower fragment has ridden up in front of the other, a- might be l from the direc- 

tion of the fracture downward and backward; and that it forms a very marked prominence anteriorly, 
so that it- posterior face, which in the norma! ; a little forward, la h'T<- wry strongly 

turn-d backward. Th«- angle thus formed maybe estimated at 135°, and during lift there must have 
been some of the appearances of luxation backward. 

i [ red from M. Hug tier. Dm 

I backward; hence the npper fragment ha- ! 
moiy— a displacement not shown in the cut, \ 
re completely. Bee pftf 



PLATE VIII. 

Figs. 42, 43 and 44. — Fracture of the outer condyle of the humerus, through, the middle of the trochlea. 
— I found this remarkable lesion in the body of a man forty years of age, who had sustained it in in- 
fancy, and in whom the forearm had enjoyed nearly all of its functions. 

In Figs. 42 and 44 the oblique line of the fracture is very distinctly seen, running up apparently about 
two and a half inches along the outer edge of the bone. Nevertheless, the greatest diameter of the de- 
tached portion does not exceed an inch and a half; so that we must presume either that the original sur- 
face of fracture of the diaphysis has been increased by abrasion, or that the fragment itself had its apex 
broken off; in Fig. 44, indeed, there may be observed some small rounded bits of bone, which may be 
considered as splinters somewhat altered in shape. There is no trace of union between the fragments — 
not even by fibrous tissue ; but they must have rubbed against one another in the movements of the fore- 
arm upon the arm, causing a sort of wearing away, which has very certainly diminished the transverse 
diameter of the detached piece ; no trace of the outer half of the trochlea is perceptible in this fragment, 
which seems to have reacted upon the diaphysis in the same way. The fractured surfaces are clean, al- 
most smooth, eburnated; and the resulting false-joint was supported only by the external ligaments. 
Fig. 44, in which the fragments are separated, shows the posterior ligaments. 

Besides this wasting, the effects of which are perceptible even upon the sigmoid cavity of the ulna, 
there presents itself another, in a manner entirely opposed to it ; this is the hypertrophy of the head of 
the radius, of the condjde of the humerus corresponding to it, of the upper extremity of the ulna, (the 
olecranon is four centimetres wide posteriorly,) and even of the remaining portion of the trochlea. 

The position of the forearm in the dead subject was intermediate between flexion and extension, as 
may be seen in Fig. 42. The outer fragment is carried up above the level of the other fractured surface ; 
the condyle is much above its normal place with relation to the trochlea ; the forearm was in consequence 
not only flexed forward, but inclined and as it were bent outward. 

Flexion could be carried beyond a right angle, (see Fig. 43,) but then it took place principally out- 
ward, the ulna abandoning the trochlea to apply itself to the lower part of the fractured surface, and the 
radius riding up so as to make the outer fragment overlap the diaphysis. 

Extension was difficult, and incomplete, (see Fig. 44;) the ulna then returned to the trochlea, the 
radius, with the humeral condyle, descended again, nearly to its normal level ; but the fragments re- 
mained separated by an interval which attested the wasting they had undergone, and which would have 
been wider had the extension been increased ; this extension was hindered, on the one hand by the hy- 
pertrophy of the olecranon, on the other by the tension of the ligaments seen in the figure. 

In this position of the fragments it is plain that the smaller one would, but for the loss of substance 
by wear, have projected much more considerably outward than in the normal state ; which accords with 
the enlargement of the articular surface of the condyle. But at the same time the tip of the smaller 
fragment is drawn forward by the muscles arising from it; a displacement not uncommon in these 
fractures. 

The humero-radial articulation has not suffered, as is seen by the excision of a portion of the capsular 
ligament, (Figs. 42 and 44.) The radio-ulnar articulation was also sound, and the movements of pro- 
nation and supination well maintained. 

Fig. 45.— Comminuted fracture of the elbow. (Musee Dupuytren, No. 90.)— Specimen presented by M. 
Calle. — This fracture was of twenty-seven years' standing, and in spite of the excessive crushing of the 
articular extremities, the elbow retained nearly all its motions. See page 468. 



PLATE VIII. 




PLATE IX. 




"PLATE IX. 

Fig. 46.— Fracture of the external condyle of the humerus, with inampUie luxation into 

—I found this specimen in a dead subject, and as is almost always the way in such cases, without pn - 
vious history. I have had it drawn as an instance of fracture limited to the condyle: bat th< I 
sent also a luxation, which calls for separate study. 

In spite of the distortion of the joint, it is easy to prove that the trochlea is unaffected. The fracture 
is seen in the figure to be outside of a line which would he the continuation of the anterioi edge of tie 
humerus; and in the specimen the fracture is found at its posterior aspect to skirt the outer border ol th< 
cavity for the olecranon, which is hardly touched. The outer fragment remains separated from 
nor are the two brought in contact by any motion: the interval is filled up by celhd.tr tissue and a pro- 
longation of the synovial membrane: above, only, there is a fibrous callus investing both frag 
quite a considerable extent. The articular surface of the condyle has disappeared; the head of the 
radius is distorted, answering to the outer fragment only by a facette formed upon its outer edge, a simila . 
facette being established upon the fragment. 

But the accompanying luxation is of still greater interest: the ulna is Been in the figure to he thrown 
inward, so that the inner edge of the olecranon is on a level with the deformed epitrochlea; the tip of 
the coronoid process answers to a new groove at the inner side of the trochlea; this latter, in.t. i ! of it- 
normal shape, presents merely a rounded prominence, just below the anterior edge of the diaj ' 
just where the narrowed part of the trochlea should be. The lesser cavity of the humerus is wanting: 
the greater is almost entirely preserved. On the whole, the luxation is a direct on:' inward of the ulna, 
without any apparent fracture of the trochlea: the head of the radius seeming to ha\ 
from the lesser sigmoid cavity of the ulna at the outset. This luxation is evidently of very ancient date. 
and time has effected some changes in it. 

In the first place, the inner facette of the sigmoid cavity, rubbing against the postei 
epitrochlea, has induced the formation upon it of a convex articular face, covered with cartil 
outer one, coming against the abrupt edge of the trochlea, has pushed it backward, forming upon it an- 
other articular face, likewise invested with cartilage. Between the two is a sort of pull . 
with synovial membrane and fibrous tissue. 

This turning outward of the inner border of the trochlea could not occur without pushing out the head 
of the radius, which bore against it by its concave end, and widening tl n the latter bone 

and the ulna. The head of the radius, therefore, presses partly against the outer edge of the trochlea, 
and partly answers to the interval between the fragments. Hence, it ha- compressed and pushed inward 
the inner edge of the trochlea, so as to obliterate the groove, and to wear a\\ ay ; i. making 

it present a vertical facette. But the pouit d'appui of the trochl i: bas devel 

into the space above it so as to be nearly a centimetre above it- usual level. Moreover, i i 
lengthen in this abnormal direction, the i-adius has bent outward at its n< ck, a- is distinctly B ien in the 
figure. 

Besides this, the head of the radius is hypertrophied from side to Bide, as i- also the ulna. 

In front of the head of the radius is seen an oblong bit of bone, and i i i process 

of the ulna: these would seem tome less likely to be Bplinters, than deposits of bone, such as at 
in the vicinity of old luxations. 

Lastly, the habitual posture of the forearm was that of semi-flexion, and its motions were very limited, 
either toward extension or more complete flexion. 

Figs. 47, 48 and 49.— Fracture of the olecrano t/tren, So. 104.) — Specimen pre* oted b] 

M. Bordet. Hulsant, a man aged 86, was admitted into the Infirmary ;it B 

and died of double pleurisy on the same day, having given do history of himself. A; the autopsy there 

was found a luxation of the left humerus, and a fracture of tie- left ell 

man's story, until he learned that the luxation had b dl on the 

ice. The patient had not submitted to any treatment. M. Bordet supposed that tl, • fracture oi 

was the result of the same accident; but this could not be positively ascertained, Hbwevei thi 

been, let us study the specimen. 

The olecranon has been detached by a fracture which posteriorly i- quite oblique, i a 
and outward, but which is much more oblique and more irregular anteriorly. On 13 
fracture has separated quite accurately the anterior and posterior bo it' - '•( tb 
the inner -id" it passes up over the olecranon, leaving a portion of the i; 
the coronoid process. Near the same point, a -mall Irregular fragnu at DAI tx • D DP id D 
cranon, and is held to it only by fibrou- tissue; and lastly, it ma; DOther little Wl I 

detached from the articular surface and driven backward, where it ha- ndhen I 



PLATE IX. — CONTINUED. 

Besides this obliquity from within outward and from above downward, there is another downward and 
forward, the level of the fracture being perceptibly higher at the posterior face of the olecranon. 

M. Bordet thought that he saw also a fracture at the inner edge of the coronoid process, united by 
hone; and the deformity at this part of the process might favor such an idea, as well as the existence of 
perceptible fissures in the articular cartilage, and the depression of the apex of the process. I have, how- 
BYer, sought in vain for any positive traces of such a fracture, and the deformity seems to me to result 
from an entirely different cause. 

It seems to me to be evident, also, that the fracture of the olecranon has been produced by crushing. 
and not by muscular action. There are, however, one or two remarks to be made. 

(1.) The base of the process is manifestly carried inward several miilimetres from its usual position; 
and as an inevitable consequence of this displacement, the small fragment of this, and that of the sup- 
posed fracture of the coronoid process, are notably borne inward also. 

(2.) On the contrary, the apex of the olecranon is plainly thrown outward, being in the same vertical 
line with the sigmoid cavity of the ulna. 

(3.) Lastly, the apex of the olecranon is inclined downward and forward more than usual, whence it 
results that the separation of the fractured surfaces is much more considerable posteriorly than ante- 
riorly. 

Thus the separation posteriorly is more than one centimetre. Union has been accomplished here by 
means of two thick lateral masses of fibrous tissue, leaving a gap between them. In front there is no 
trace of union for a distance of three or four millimetres and more from the articular surface : and espe- 
cially in the inner half, the fibrous tissue is almost confined to the posterior surface of the bone, without 
penetrating, so to speak, between the fragments. 

From the inclination forward of the apex of the olecranon has resulted a flattening of that of the coro- 
noid process, explained better in this way than by a separation of which I see no sufficient evidence; but 
whatever was its cause, this alteration of the sigmoid cavity must have notably interfered with extension 
of the forearm. 

The coronoid fragment, carried inward, plays upon the inner edge of the trochlea. The radius showed 
no change either in its form or relations, except, perhaps, that a small bony growth existed near the pos- 
terior limit of the radial facette of the ulna. 

Fig. 50. — Fracture of the left radius in its lower third. (ATuste Dupuytren. No. 100.) — Specimen pre- 
sented by Professor Breschet. — The forearm is seen from behind ; the position of the articular surface of 
the radius indicates complete pronation. The fracture may be traced, through the very firm callus, run- 
ning somewhat obliquely downward and outward, so that the overlapping might have been expected to 
carry, as it has done, the lower fragment inward, the upper one remaining in place, or even deviating 
somewhat outward. Hence the narrowing of the intercostal space below, while above it is, to say the 
least, maintained. The overlapping, moreover, has not done everything: it was limited by the inferior 
radio-ulnar ligaments, so that the inner portion of the articular face of the radius has kept its place: 
but the styloid process is so raised up that the ulna, if the two bones were rested upon the two styloid 
processes, would incline somewhat outward, instead of inward, as in the normal state of things. It is. 
then, mainly this riding up of the radial styloid process which has tilted the lower fragment inward, a 
movement limited only by the ulna, against which this fragment rests, and to which it is connected by 
fibrous tissue. It is also carried a little forward, while the upper one points backward. Lastly, it may 
be remarked that this latter is rounded off at its broken end, more than the original shape of the bone 
can explain; tlris is due to absorption of the bony texture from the pressure of the skin and aponeurosis, 
and attests the age of the fracture. 

Fig. 51. — Fracture of both bones of the forearm, with displacement of aU four fragments. — The frac- 
ture of the radius is seated at the junction of the lower with the middle third of the bone: that of the 
ulna in its lower fourth. The lower fragment of the ulna has passed up backward, that of the radius 
forward, involving a very marked displacement by rotation; the lower portion of the forearm being al- 
most pronated. while the superior remains nearly supinated. The residt of this rotation has been that 
the lower fragment of the radius, carried in front of the upper fragment of the ulna, is separated by it 
from the lower fragment of the ulna, so as to preserve the interosseous space almost entire below, while 
higher up it is considerably narrowed by the approximation of the superior fragments. See pages 472 
and 473. (On page 473, line six. for " 52" read " 51.") 

Fig. 52. — Fracture of both bones of the forearm at about their middle. — See page 472 



PLATE X. 

Fig. 53. — Fracture of both bones of the forearm at the same level, five centimetres from the torist, willi 
luxation inward of the ulna. — This specimen was taken from a woman aged 25, without previous his- 
tory. Both fragments of the radius are inclined inward toward the ulna. The lower radial fragment 
has also ridden up upon the other, as well as upon the ulna; hence the change of level of the articular 
face of the radius, and a luxation of the ulna inward. See pages 474 and 483. 

Figs. 54, 55 and 56. — Recent fracture of the lower extremity of the right radius, and of the styloid pro- 
cess of the ulna. — Specimen presented by M. Maisonneuve. — The fracture was at the fourteenth day; but 
the pneumonia which carried the patient off had hindered the work of repair. Fig. 54 shows the anterior 
aspect of the bones, Fig. 55 the posterior; Fig. 56 shows the transverse direction of the fracture, inter- 
rupted however by numerous serrations. See also page 487. 

Fig. 57. — Fracture of the lower extremity of the right radius, in process of consolidation with de- 
formity. — This specimen was taken from a woman who died about four weeks after her accident; but the 
malady which carried her off had retarded the formation of the callus, and the bone having been sub- 
jected to maceration, an important part of the callus disappeared. 

The radius is seen from one side; the anterior faces of the two fragments have remained in nearly the 
same vertical plane, but the lower piece is a good deal tilted backward. Thus the anterior edge of the 
articulating surface is no longer prominent ; the styloid process is raised to the same level with it, and 
the posterior edge is still higher yet. The upper fragment seems to bury itself posteriorly in the spongy 
texture of the lower one, and the angle here formed Avas previous to the maceration entirely filled up by 
a deposit of callus. Of this there remain only a few slight traces, two or three centimetres farther up 
on the upper fragment; but in Fig. 59, taken from an older fracture, the callus is seen passing obliquely 
up along the diaphysis, and filling an angle at least as wide as that in Fig. 57. See pages 489 and 490. 

Figs. 58 and 59. — Old fracture of the lower extremity of the radius, with vicious consolidation. — In 
Fig. 58 the bones are seen by their posterior faces ; but nearly the whole articular surface of the radius 
appears, showing how niuch its posterior edge is carried above the level of the anterior. This is still 
more evident in Fig. 59, where the degree of elevation is seen to be thirteen millimetres ; the anterior 
face flattened, the posterior making an abnormal prominence, and the posterior wall of the diaphysis 
buried in the spongy texture. But this spongy texture hardly belongs to the original bone ; the greater 
part of it is formed of callus, which has filled up the angle between the upper and lower fragments. 
Fig. 58 shows also the styloid process of the radius on a level with that of the ulna, or even a little above 
it ; and as the interosseous space is not lessened, it is clear that the carrying up of this process depends 
on the tilting backward of the lower fragment, and not on its inclination toward the ulna. See page 489. 

Fig. 60. — Fracture of the second metacarpal bone, with overlapping and inclination forward of the 
lower fragment. (Musee Dupuytren, No. 110.) — The bone is seen at its inner face, i.e. the one turned to- 
ward the third metacarpal. The fracture seems to have been oblique downward and forward; the lower 
fragment, overlapping the other, makes a very marked projection at the back of the hand, while its head 
is inclined toward the palm. Besides this angle, which is well shown in the figure, there is another less 
perceptible one, in virtue of which the lower fragment is carried to the outer side of the superior, and 
its head turned very much inward. There must have been during life shortening of the index finger, 
an inclination of this finger toward the palm of the hand, and at the same time toward the third meta- 
carpal, and lastly a prominence at the back of the hand, toward the thumb. 

Fig. 61. — Very oblique fracture of the second metacarpal bone, united with hardly any perceptible dis- 
placement. 



PLATE X. 



53 




PLATE XI. 




PLATE XI. 

Figs. 62, 63 and 64.— Fracture of the cervix femoris, dating batik six months and a htdf; intra-cap- 

sular above, extracapsular below.— Eustache, aged TO. fell directly upon the great trochanter 

1S41. I detected a fracture of the neck of the bone, probably intra-capsnlar, and put the limb on ■ 

doable inclined plane. About the 16th of July. I tried to make him get up; but acute pain> in the hip 
prevented his doing so. Toward the end of August he could walk with crutches; but the pains coming 

on again, he took to hi? bed. where he remained until he died, on the Tlh of December. 

The foot was very little everted: the trochanter was more prominent than that of the sound Bide, and 
described a large arc when the limb was rotated; the rotation Beemed t>> take place in the joint, bo that I 
doubted whether the fracture were not extra-capsular. But upon dissection the state of things was 
found to be as shown in Fiy- 62: only that the synovial membrane lining the capsular ligament was ad- 
herent to that covering the neck, at the seat of the fracture, and that nearly all the cartilage of the head, 
and the round ligament, seemed wanting: it was almost entirely blended with the pad of fat, forming 
with it a uniform reddish mass; and the head of the bone, thus fixed to the bottom of the cotyloid cavity, 
did not share in any movement of the limb. 

The head of the femur, situated below the level of the trochanter, has been detached from the Q< ek by 
a fracture running downward and inward, commencing above just at the junction of the cartilage of 
incrustation with the synovial membrane, and terminating below about two centimetres to the outer side 
of the cartilage, consequently outside of the capsule. The trochanter, with the shaft of the bone, is car- 
ried upward and somewhat forward, and the head of the bone has descended so as to rest against the 
hanteric line, a little above the lesser trochanter. {Fir/. 63.) The upper edge of the cervical 
fragment is therefore notably above the level of the head: it has remained separate from it. and the 
fractured surface at this point is covered with a smooth white cartilage. Lower down, there Ifl Mill an 
interspace of one or two millimetres between the fragments: the cervical surface is covered with rod 
granulations, which do not appear upon the other: and lastly, union by fibro-cartilaginous tissue has 
commenced at several points. (Fig.GS.) In this same figure an attempt bas be< a made to ghovi a rery 
Carious point. Entirely outside, the spongy texture of the trochanter has it > ordinary yell « til 

he fracture and in three-quarters of it> thickness, it is of a deep nil color. So also in the lead 
of the femur, the spongy tissue of the upper fourth, where the separation is complete, is y< l!-\\ and hard, 
as if necrosed; the remainder of it is red. as is seen even through the incrusting cartilage. 

5 and 66. — Intra-eapsular fracture of nine months' standing; no tract of union.— Louis Marie, 
aged 73. was thrown upon his buttocks by some one polling away a chair in which h was ;; i 
down; he was able to rise and go to his room, and could walk the next day; the day after, Jul; 
he came to tin- infirmary. At the end of five months he went out; he limped a littli in walking, «a< 
easily fatigued, and could not stand long at a time. He died April -4. 184L 

The foot was not more everted than the other: but it could not be turned inward, being am Med in the 
vertical position. The shortening was at most about one inch. The thigh could be completely < xtended 
upon the pelvis, and flexed to an angle of more than 45°; adduction was as easj as in the sound limb, 
but abduction was almost impossible. 
The capsule was infiltrated bright red in the vicinity of the cotyloid cavity; the round ligament and 
pad presented the same tint. The fracture was entirely tatra-capsular, and the head of the 
bone connected with the capsule only by adhesi may be seen in the Bame figure that do 

union of any kind has taken place between the fractured surfaces. The head, much diminis hed in thick- 

the side next the fracture, where it presents do trace of an j | 
But upon its articulating surface are seen irregular d< posits of b a Heating a kind 

trophy. The fractured surface of the cervix would seem at first to have been likewtsi 

: out. on measuring the thickness of the bone at this part, it i- found to I 
. by tie- addition of thick, glistening, eburnated plate- ,,f bone. 
In these two drawings we see a curious transformation of tie- lesser trochanter into an eburnated 
rered with a synovial bursa, but separate from tie- articular cavity. In Hi rlon, the lead de- 
scended to tins point, and the bursa was probably the result of friction. 

What i- particularly striking in this case i? the recent date ,,f the fracture. \ 
possible in so short a time, or did the patient's memory deceive him I 



PLATE XII. 

Fig. 67.— Old intra-capsular fracture, with considerable shortening.— I found this fracture in the body 
of an old man, whose previous history was unknown. The body rested naturally upon the left side, and 
in fact could not remain upon the back; for the right lower extremity, in which was the fracture, was 
adducted and rotated inward, so that the axis of the trunk fell an inch to the outer side of the right knee, 
and the right foot rested on the table by its inner edge. 

The fracture seemed to be seated just at the junction of the head and neck of the bone ; the head was 
unconnected with the capsule, but adhered to the cotyloid cavity by reddish false membranes, which 
had taken the place of the cartilage at various points. The fractured surfaces were united only by some 
fibrous and membraniform bands, of considerable length. The head seemed to have lost thickness: the 
other fragment showed no very marked trace of the cervix, but its thickness was not apparently dimin- 
ished. 

The femur being drawn up, and at the same time adducted, the head is depressed upon the lower part 
of the cervix, even down to the lesser trochanter, where an articular facette has been formed ; part of the 
psoas tendon is transformed into a movable osseo-fibrous plate, as if to complete this facette. The capsule 
seems to have been worn away below, and to have been replaced by a thin, soft, cellular membrane, ex- 
tending from the edge of the cotyloid cavity to below the lesser trochanter. Above, on the contrary, the 
capsule, although stretched, is quite thick, and even contains cartilaginous nodules here and there; it 
was owing to this tissue that the femur did not ride up more. The shortening amounted, however, to 
nearly two inches, not including that due to the adduction of the limb. 

It should be added that the head was not in contact with the cervix at all parts of its fractured surface. 
The points of attachment of the fibrous bands were just those where there was no contact; all the parts 
subjected to friction were eburnated. 

Figs. 68 and 69. — Ununited extracapsular fracture, with division of the base of the great trochanter.— 
Messager, a decrepit old man, eighty-seven years of age, sustained this fracture by falling from his chair 
upon his right hip, June 2, 1841. I put him upon a double inclined plane until July 10 T after which he 
kept his bed, from debility; drinking freely, but eatina; little, and sleeping constantly. He remained 
thus until the latter part of August, when scorbutic symptoms appeared ; soon after this, a slough formed 
over the sacrum, and on September 4 he died. 

The fracture, although of three months' standing, showed no sign of consolidation having begun. I 
have had it drawn with the fragments in their proper positions ; the fracture is seen to be entirely out- 
side of the capsule ; the greater trochanter is detached at its base, the fragments not corresponding ex- 
actly, partly from the edge of the lower fragment being worn away, and partly by the loss of a number 
of little splinters. Nearly all the spongy tissue within the neck has been crushed up ; except two pieces 
seen in Fig. 69. 

In the body, the lower portion of the part of the neck attached to the head was buried in the shaft, 
exactly as is seen in Figs. 70 and 71 ; the head was very much inclined downward, and the trochanter 
depressed inward and backward, lying, as it were, upon the summit of the shaft. It was friction upon 
the cervix which had worn and polished the edge of the lower fragment, and it was this edge which, pre- 
venting the cervix from descending farther, had limited the shortening. 

The fragments being entirely unconnected, I tried the effect of extension in this subject. My experi- 
ments are detailed at page 566; but a glance at this and the two following drawings will show clearly 
that traction in a straight line, made upon the head and shaft of the bone, could never bring the frag- 
ments into their proper relations. 

Fig. 70. — Extra-capsular fracture, united, with fracture of the greater trochanter. — I have given in my 
memoir Sur quelques dangers du traitement ordinaire des fractures du col du femur, the clinical history 
of this case. I may say here that the patient, whose name was Lambert, was coachman to M. Roux, and 
was treated at La Charite by Boyer, and by M. Roux himself. In spite of powerful continued extension, 
which lacerated his groin and ankle, and induced mental disorder, he retained a shortening of three and 
a half centimetres. He died at Bicetre, at seventy years of age, about sixteen years after his injury. 

In the figure, the lower part of the cervix is seen so driven into the diaphysis, that the head of the bone 
is almost in contact with the inner wall of the latter ; and it is easy to see, from the contact of the com- 
pact wall of the diaphysis with the spongy texture of the cervix, that the length of the limb has not been 
increased a single millimetre by the continued extension. A line of compact bone reaches from the point 
of junction up into the centre of the head itself; this is merely an adventitious formation. 

Another fracture had separated the anterior and superior portion of the greater trochanter. To judge 
of the degree to which the tip of this epiphysis has been driven inward, we need only compare with this 
Figs. 62 and 68, in which the trochanter is represented in its normal state. 

Fig. 71.— Consolidated intra-capsular fracture, with fracture of both trochanters. — I do not know the 
history of this specimen, which belongs in my own collection; on the one hand, the head of the femur is 
seen to be hypertrophied, and its edge folded over on the cervix, like a mushroom, indicating senile dis- 
ease of the hip-joint; on the other, the lower wall of the cervix is so driven in as nearly to reach the oiiter 
wall of the diaphysis. So far, the appearances are almost the same as those in the preceding figure; but 
here both walls of the diaphysis are evidently fractured at the same level, and in the specimen the two 
trochanters were seen to be separated together from the rest of the bone; so that the cervix has descended 
much lower, and the shortening must have amounted to five or six centimetres. Here, as in the preceding 
figure, the tilting inward of the tip of the greater trochanter should be observed. 



PLATE XII. 




PLATE XIII. 




PLATE XIII. 

Era. 72.— Fracture just below the trochanters, with deformed callus. (Museum at Falrde-Gfrtice.)— The 
femur is seen in front. The fracture seems to have been seated just bdow the trochanters; the lowei 
fragment has been drawn up behind the upper, which is strongly abducted, SO that the head of the bone 
i 5 inclined very much inward and forward. An enormous callus envelops both fragments posteriorly, and 
a very large stalactite is seen coming forward under the head and neck of the bone, as if to support them. 

It is remarkable that the upper fragment, although in front of the Other, has not been flexed in the 
-lightest degree: on the contrary, it may be said to be pushed backward toward the lower fragment. 

This lower fragment is thirty-four centimetres in length, from the inner condyle; the upper, about 
tight centimetres, measuring from the seat of fracture to the tip of the greater trochanter— in all. 43 
centimetres: and the head of the bone being one or two centimetres above the level of the greater tro- 
chanter, the entire length of the sound bone must have been 43 or 44 centimetres. Now in ii- present 
Condition the femur, measured from the inner condyle to the tip of the greater trochanter, Is Old] 88 
centimetres in length, showing the shortening due to the overlapping to be about three centimetres; ami 
from the inner condyle to the summit of the head of the bone, the distance is but thirty-seven and a halt 
centimetres, showing a shortening of two and a half to three centimetres due to the inclination "t the 
latter. 

Fit.. 73. — Fracture six centimetres below the lesser trochanter. (Museum at Val-dc-Grdce.) — The femur is 
- ii in front. The upper fragment is strongly tilted outward: it does not project forward more than 
one centimetre. The section made opposite the callus shows sufficiently the relations of the twofragm into; 
I il overlapping does not exceed one centimetre. 

How the length of the lower fragment, measured from the inner condyle, is 2S centimetres; that of the 
upper fragment, from the tip of the greater trochanter, is 14 centimetres — in all. 42 centimetres. In it* 
ndition. the bone measures only 40 centimetres from the trochanter to the condyle, and at most 
39 centimetres from the condyle to the top of the head of the bone. The entire displacement amounts, 
therefore, to three or four centimetres, only one of which is due to overlapping, and the rest to angular 
displacement. 

fte. 74. — Double fracture in the upper third of the diaphysis. (Museum at Valrde-Ordce.) — The femur i- 

seen in front. The upper fragment is carried strongly outward, hardly at all forward; the middle one j- 
behind the upper, and outside and in front of the lower oue. Upon superficial examination, smh a result 
1 at: and even upon measurement, the lower fragment is twenty-nine, the middle six. 
and the upper one eight centimetres in length: (the fractures being very oblique, the tips of the fragments 
■ ired from.) The femur should therefore measure from the greater trochanter to the ium i OOn- 
itimetres, end does actually measure 4U; but its length from the condyle to the tip of it- bead, 
Which should be 44 or 45 centimetres, is reduced to :JS : an excessive shortening, due in great part cer- 
tainly to angular displacement. 

— Oblique fracture at the middle of the femur. (Museum oi Faliie-Qr&ae.)— -The feaivu 

from one side; it has been sawed open antero-posteriorly : in the figure it i- Been that the posterior wall 

"f the -haft has bf.-n separated a little higher op than the anterior, but the tip of the lower fragment i- 

d drawn very much up behind the other. The overlapping has been arrested here bj the two 

- uning in contact; tie- posterior wall of the -haft in the upper one bearing against the anterioi 

wall in the other. They formed also an angle salient outwardly, which eon! 1 not be shown in >i 

mi 1 77. — Fracture in (hi middle third of fht femur, with widt tuatty interlocked. 

■ t ossified, but has sufficient firmness to keep thi 

apart. The upper fragment i- indeed carried somewhat outward (Fig. 76) and farwai ' I 

still it presents two large serration-, which, by Interlocking with COTTPHfonrtltlg indentation- in the lOWSJ 
fragment obviate any overlapping. 



PLATE XIV. 

Fi.;. 78. — Fr.ictin; ■■just above the condyles of the femur. (Musee Dupuytren, No. 150.) — This fracture ran? 
obliquely downward, outward, and somewhat forward: the upper fragment, displaced in this triple man- 
ner, has pushed the patella downward as far as the tibia, so as really to luxate it downward. The other 
fragment has remained parallel with this one. 

Figs. 79 and SO. — Transverse fracture of the patella, united by bone. — I found this specimen in the body 
of a man who had on the left side the much graver lesion represented in Fig. 84. The first was not sus- 
pected during life. In Fig. 79 there is seen a solution of continuity of the cartilage, involving its whole 
width and thickness: at each end, for a distance of one or two millimetres, union seems to have occurred 
in the middle there is nothing of the kind. At its anterior face (Fig. 80) the bone presents a transverse 
groove of slight depth, about five millimetres in width, filled up at its inner extremity, and denoting a 
separation made good by bony deposit. 

Fig. SI. — Transverse fracture of the patella, united by fibrous tissue. — This specimen was taken from an 
old man at Bicetre. who two years before his death had broken the patella by a fall, his knee striking a 
step. The separation in the dead body was three fingers'-breadths; it was therefore much increased upon 
direction. The ligamentum patella?, greatly thickened, was but three centimetres long at its posterior 
face ; in the other limb it was six. 

I have mentioned (page 609) the constituents of the fibrous tissue uniting the fragments, and also (page 
610) the curious tilting of the lower fragment, so that its posterior face looks directly upward. Both 
fragments were in a state of evident hypertrophy. 

Fig. S2. — Transverse fracture of the patella, united by fibrous tissue. (Muste Dupuytren, Xo. 202.) — This 
figure is intended to show the inclination forward of the lower fragment : the fractured surface presents a 
plane inclined forward and downward, which would lead one to suppose, but for the light given by the 
preceding figiu'e, that the fracture had separated the bone in this direction. In the specimen this inclina- 
tion was clearly due to the tilting of the fragment, since the point of the lower fragment was carried back- 
ward. 

The upper fragment itself seemed to be inclined backward by its upper end, as if the fracture had been 
treated by double pressure. Lastly, upon its anterior surface were deposits of new^ bone, giving it a thick- 
ness of two and a half centimetres. 

Fig. 83. — Comminuted fracture of the patella, united by fibrous tissue. 

Fig. 84. — Fracture of the patella united by fibrous tissue, recurring twice, and at last followed by death. — 
Denton, aged 61, had had several years previously a transverse fracture of the left patella, united by 
fibrous tissue, which had been ruptured and reunited : he slipped and fell backward on the 7 th of February. 
1839, when the callus gave way for the second time. But at the same time the skin over the knee was 
greatly ecchymosed ; a slough formed, laying open the articulation, and on the 2d of March he died. 

The fragments were separated to an extent of five or six centimetres, with hardly any traces of the 
fibrous callus. Their articulating surface is seen in the figure. The upper one is deformed; a crescentic 
zone, covered with periosteum, occupies its upper part for a width of eight to fifteen millimetres ; the 
portion which is still covered with cartilage is limited above by this zone, below by a prominent bony 
ridge running the whole length of the fracture. The lower fragment is almost entirely stripped of car- 
tilage, and corroded by suppuration. It would seem to comprise two portions; one, representing its ori- 
ginal form, is two and a half centimetres in vertical diameter; the other, situated above this one, is a 
bony prolongation two and a half centimetres in width by one in vertical diameter, which would seem 
sent up toward the upper fragment; and as the vertical diameter of the latter is three centimetres, the 
bone has acquired a vertical diameter of six and a half centimetres, while the other patella of the same 
subject (Figs. 79 and 80) measures at most only four and a half. 



PLATE XIV. 




PLATE XV. 




PLATE XV. 

- " .—Fracture above Vu condyles offkefemur, apparently transverse. (Miisee Dupuytren, No. 135.) — 
Hie fracture is seated 11 or 12 centimetres above the condyles. Both fragments have maintained almost 
entirely their vertical direction; but the lower one is drawn backward about two centimetres. The over- 
lapping is about five centimetres, and the anteroposterior diameter of the bone is more than doubled at this 
point. The callus is formed by two large masses of bone, the inner of which is five centimetres in width. 
nda obliquely from the upper to the lower fragment: the outer one. only three centimetres wide, 
:tly transverse direction. Above this latter i- seen the orifice of a canal drilled vertically in the 
callus, closed up interiorly, and of the same calibre as the medullary canal of the femur. The effort at 
ms to have been limited to the corresponding faces of the two fragments; the medullary canal 
main op n in the lower fragment, and the same was the case with the upper. 
This displacement, and this disposition of the callus, give the specimen considerable importance; hut it 
1 more from the apparently transverse direction of the line of division. The upper extremity 
of the I( »wer fragment is indeed seen to be squarely cut : but on the other hand the surface thus presented 
i.-. .>nly two .:•. ntimetres in width, indicating a loss f substance in the bone transversely, while the upper 
it obliquely at its anterior face. It might however be alleged that this was due to 
_ of the soft parts; and the only way to decide the point would be 

ne vertically from before backward. This section I had made quite recently: it showed 
th- anterior wall of the shaft to have been divided at a much higher level than the other, so that the frac- 
wnward and backward. 

. tiy of the tibia, oblique downward and forward. — The inner face 
h iwn; behind it the fibula is seen to be fractured in its upper fourth. 

7 — /■'/ and backward. — The bone is seen at its inner side. 

,/ .(,"/ inward. — Both bones are seen in front: the, fibula 
: d at ab rut the same level, proving the cause to have been direct violence. 

and 93. — Fract ■ ■. obliqiu downward and inward. — Here the fibula i< broken 

up than the tibia, showing the violence to have been indirect. 



PLATE XVI. 

FlG3. 91 and 92. — Fracture of the lower part of the leg, by crushing.— The patient, an old man. was 
thrown Erom a third story window, and died a few hours afterwards. 

Fig. 8) Bhows the hones as seen in front. The inner malleolus is detached, the line of fracture being 
antero-posterior, as seen in Fig. 92. The tibia is fractured in its spongy portion, very irregularly, pre- 
senting large rough serrations, with gaps left by the loss of several small splinters. The lower fragment 
is itself divided vertically from right to left, down as far as its articulating surface. (Fig. 92.) Lastly, the 
fibula is broken a little higher up; its malleolus, remaining intact, preserves its relations with the tibia. 
There is very marked angular displacement; the upper fragment of the fibula forming the apex of an 
angle salient inward, and elevating the skin by its sharp point. 

FlG. 93. — Fractures of the lower extremities of the tibia and fibula, and of the posterior extremity of 
the calcaneum. (Musee des Hopitaux.) — The outer aspect of the specimen is shown, so as to display flic 
fracture of the calcaneum. The posterior portion of this bone is in the first place separated by a vertical 
fracture running from side to side ; there are also some wide but very thin splinters detached from its 
outer face. Its anterior portion is intact. 

The fracture of the fibula is seated a little above the articulation, the malleolus remaining entire. In 
front, a large piece is seen separated from the tibia; another, still largei-, comprises the whole inner mal- 
leolus; a third, much smaller, is formed of part of the articular surface, and is buried in the spongy por- 
tion of the bone. The articular surface therefore presents one division from before backward, and 
another running transversely, as in Fig. 92; besides an imbedding of a splinter separated from its an- 
terior part; while its posterior portion remains perfectly sound; the crushing has affected only the front 
part of the bone. 

Fig. 94. — Fracture of the lower extremity of the fibula, by abduction. (Musee des Hopitaux.)— -This case 
was published by M. Maisonneuve in the Arch. Gen. Med., 1840, tome iii, p. 171. (See text, pages 653 
and 656.) 

Fig. 95. — Fracture of the lower extremity of the fibula, supposed to be by adduction. (Musee des Ho- 
pitaux.) — The entire specimen comprises both bones of the leg, with the astragalus and calcaneum; but 
as the fibula is the only bone affected, it is shown by itself. 

The fracture commences on the outside, six centimetres from the malleolus, and shows quite marked 
serrations, into the most considerable of which fits the summit of the lower fragment. Thence it de- 
scends very obliquely inward, so as to terminate near the middle of the tibio-peroneal articulation, and 
two or three millimetres from the tibio-tarsal. The two fragments remained attached to the tibia, but it 
may readily be imagined how feeble the connection of the lower fragment was. 

Fig. 96. — Fracture of the lower extremity of the left fibula. (Musee Dupuytren, No. 231.) — The specimen 
consists merely of the fibula. The fracture is of ancient date, and consolidated with very marked tilting 
outward of the lower fragment; it is, like the preceding, directed obliquely downward and inward, the 
two specimens being strikingly similar. The fracture extends upward to six and a half centimetres from 
the tip of the malleolus, and below to a few millimetres above the articular facette. The lower fragment 
has been carried outward some four millimetres, but en masse, without any tilting. The upper fragment 
seems also to have been separated from the tibia. Lastly, there springs from the front of the bone, near 
the upper termination of the fracture, a bony stalactite like the styloid process of the temporal, pointing 
transversely inward. 

Fig. 97. — Double fracture of the right fibula, probably by direct violence. (Musee Dupuytren, No. 230.) — 
The inner face of the bone is seen. Six centimetres from the tip of the malleolus there is a nearly trans- 
verse fracture, the upper fragment of which is thrown backward. Nine centimetres higher up is an- 
other fracture, not consolidated; the upper fragment is wanting; the end of the lower is rounded otf, and 
the medullary canal obliterated. 

Figs. 98 and 100. — Crushed fracture of the calcaneum, at the forty-eighth day. — An insane man, aged 
45, jumped from a height of seven or eight yards, alighting on both heels; both calcanca were broken. I 
applied lateral splints, which were kept on until the thirty-third day. An intercurrent affection carried 
off the patient on the forty-eighth day. 

Fig. 98 represents the right calcaneum; it is crushed especially at the level of its larger articular 
facette, where its thickness is reduced to three centimetres. Fig. 100 shows by a horizontal section the 
abnormal increase in its width. The specimen, at the level of the lesser apophysis, is six and a half cen- 
timetres wide, the excess affecting chiefly the inner side. Fig. 100 shows the lacuna? left in the callus, 
even after so long a time; the interspaces between the fragments are just filled by spongy tissue, redder, 
softer and less dense than the bony texture ; at several points the union is through the medium merely ot 
a soft, tomentose, membrane-like substance. 

Fig. 99. — Crushed fracture of the calcaneum, at the thirteenth day. — See text, page 670. 



PLATE XVI. 




' £ 906 1, 



ggg 38S8 

I iBK" llfflir i 1 

955 ^^KSL 

gg HBHH ^^HB 



LIBRARY OF CONGRESS 



021 067 542 5 




HKHe 
■ ■ 




iBiM 



URN Hi 




